Every finding on record at Great Plains Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 2 residents observed for infection control. -CNA A did not perform hand hygiene correctly when providing incontinent care for Resident #1. This failure could place residents at risk for the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.Findings include: Record review of Resident #1's face sheet printed 8/18/2026 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning), metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and Parkinson's (a disorder of the central nervous system that affects movements to include tremors). Record review of Resident #1's MDS printed 8/18/2026 was a quarterly completed 4/15/2026 with a BIMS of 12 indicating she was moderately cognitively impaired, and she had a functionality of requiring supervision/touch assistance with toilet hygiene. Resident #1 was listed as occasionally incontinent with urine and bowel. Record review of Resident #1's care plan printed 8/18/2026 with admission date of 6/11/2026 revealed the following: The resident has bladder incontinence. Dementia, Loss of peritoneal tone. Date Initiated: 5/19/2026. During an observation on 8/18/2026 at 09:36 AM CNA A performed incontinent care for Resident #1 with CNA B's assistance. CNA A removed her gloves and washed her hands, placed new gloves and then CNA A and CNA B rolled Resident #1 to her left side. CNA A then pushed Resident #1's used draw sheet and used brief under Resident #1. CNA A then opened a new brief and placed the new brief along with a clean draw sheet under Resident #1. CNA A then removed her gloves, washed her hands, placed new gloves, and rolled Resident #1 to her right side with CNA B's assistance. CNA A then removed the used draw sheet and used brief from the bed, placed them in a trash bag, and then finished unrolling the clean draw sheet and new brief from under Resident #1. CNA A then rolled Resident #1 to her back. CNA A then removed her gloves, washed her hands, placed new gloves, and finished securing the new brief for Resident #1. During a group interview with CNA A and CNA B on 8/18/2026 at 09:52 AM CNA A confirmed she contaminated her hands when she touched the used draw sheet and used brief when Resident #1 was on her left side but felt she did not contaminate her hands when Resident #1 was on her right side because the used brief was folded up in the used draw sheet and her gloved hands never touched the used brief. CNA A reported not following proper hand-hygiene during incontinent care can result in infection and CNA B reported residents can get germs. Both reported they are trained frequently on multiple subjects, including incontinent care and catheter care. They stated, it seems like we are trained every month on them. They reported they are trained by online training, video, and the DON. During an observation and interview on 8/18/2026 at 09:56 AM Resident #1 was observed in her bed laying under her covers in a clean well-kept room with her call light attached to her bed. Resident #1 reported she had received good care and she had no issues with the facility. During an interview on 8/18/2026 at 12:44 PM the DON reported she expects staff to change their gloves and wash their hands anytime when touching a dirty surface before continuing to a clean surface. The DON stated, If they come into contact with a dirty area then their hands are contaminated. The DON reported that if staff do not follow proper hand hygiene, then a resident will become contaminated, they can get an infection. Record review of the facility provided in-service dated 5/28/2026 revealed the following: Subject: Peri-CareSummary of Subject Matter:6.wash your hands in between dirty and clean.Signed by CNA A. Record review of the facility provided in-service dated 4/15/2026 revealed the following: Subject: Proper Peri-CareSummary of Subject Matter: Infection Control/UTI prevention3. Wash hands frequently before stating peri care and before going from clean to dirty or when gloves are visibly soiled.Signed by CNA A. Record review of the facility provided policy titled Fundamentals of Infection Control Precautions undated, revealed the following: 1. Hand Hygiene-Hand Hygiene continued to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:-Upon and after coming into contact with a resident intact skin.-After using soiled or used linens.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored, labeled, and dated from 08/04/2026 through 08/06/2026 by not properly labeling or dating opened or frozen foods as well as covering and labeling food that had been prepared. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.Findings included: In an observation on 08/04/2026 at 9:43 AM revealed: Four clear bowls with cereals by door not covered, labeled, or dated.2 clear bowls filled with pudding-like substance in yellow color was located by the door, not covered, not labeled, and not dated. box of instant mashed potatoes, 26.7 oz- box is opened and not placed in a clear sealed back or plastic container.In an observation on 08/04/2026 at 9:54 AM, revealed an unlabeled, undated clear bag of fruit. In an observation on 08/05/04 at 6:52 AM, revealed mashed potatoes box- 26.7 oz, opened and not in a sealed bag or container. grape and strawberry jelly, 20 oz., dated 8/4/2026,sitting at the bottom of prep table, with instructions to refrigerate after opening. In an observation on 08/05/2026 at 7:17 AM, grape and strawberry jelly remained on the bottom of the prep table. In an observation on 08/05/2026 at 10:43 AM revealed grape and strawberry jelly remained on the bottom of the prep table. In an observation on 08/05/2026 at 12:31 PM revealed grape jelly remained on the bottom of the prep table. In an observation on 08/06/2026 at 8:35 AM revealed a grape jelly on the bottom of the prep table on top of a white bucket of peanut butter. In an observation on 08/06/2026 at 8:29 AM revealed 2 tulip bowls with cereal that appears to be, by kitchen door was uncovered, unlabeled, and undated. In an interview on 08/06/2026 at 9:22 AM, DA A was interviewed with [name of interpreting service]. DA A stated that she was trained by DM on how to store and label food in the kitchen. DA A stated she speaks to DM every day on how to properly do things in the kitchen to make sure it is done correctly. DA A stated that she labeled items with the date, time, name of item, and then next date after 10 days. DA A observed grape jelly bottle and stated it said to refrigerate after opening and it is supposed to be in the refrigerator. DA A stated the box of mashed potatoes was not stored properly and should have been in a bag. DA A observed uncovered cereal bowls by door and stated bowls should be covered. DA A stated a negative outcome of not storing items correctly could cause someone to get sick. In an interview on 08/06/2026 at 9:33 AM, DA B was interviewed with [name of interpreting service]. DA B stated the manager and other worker no longer worked at the facility who trained her on storing and labeling items in the kitchen. DA B stated she was trained two years ago. DA B stated the proper way to store items is when the item is opened, it is to be labeled, dated, and stored. DA B stated jelly needed to be stored in the refrigerator after it was opened. DA B stated that jelly bottle indicated that it needed to be refrigerated after opening. DA B stated the mashed potatoes were not stored correctly ,they should have been covered. DA B stated cereal bowls by door should be covered. DA B stated a negative outcome was that residents could get sick to the stomach. In an interview on 08/06/2026 at 9:41 AM, the DM stated training had been going on for two weeks. The DM stated that items are to be put in a bag or container, labeled, dated for seven days after open date. The DM stated mashed potatoes were not stored properly or according to policy and should be in a zip locked bag. DM stated the jelly should have been refrigerated. The DM stated the cereal bowls by door should have been covered. The DM stated a negative outcome of food not stored or labeled properly could cause residents to possibly get a stomach bug or not feel good. Record review of policy Food Storage and Supplies, dated 2012, stated under line item 4.- Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. Line item 8.- Perishable food have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply and this is what causes the food to deteriorate in quality and taste. If perishable foods have not been stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food become spoiled and should not be served.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 of 12 residents (Resident #18) reviewed for advanced directives. Resident #18's OOH-DNR, signed [DATE], was not correctly completed as Resident #18's FM signed the OOH-DNR in the Person's Signature area on the form. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR could cause harm and goes against resident's wishes.Findings Included: Record review of Resident #18's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with a readmit on [DATE]. Resident #18's diagnoses included nontraumatic intracerebral hemorrhage (type of stroke that causes bleeding in the head), chronic pain, major depressive disorder (serious mental health condition characterized by persistent feelings of sadness), and need for assistance with personal care. Record review of Resident #18's quarterly MDS, dated [DATE], revealed under Section C, resident was coded a 0 for question C0100 indicating that resident was rarely/never understood and does not have a BIMS score documented. Record review of Resident #18's care plan, dated [DATE], revealed a focus of Resident has an order for Do Not Resuscitate (DNR) initiated [DATE]. Record review of Resident #18's OOH-DNR form, dated [DATE], revealed FM signed the bottom of the form by Person's Signature. Record review of Resident #18's orders, with a revision date of [DATE], revealed an order for DNR. In an interview on [DATE] at 8:45 AM, LVN C stated that DNR status is found in the EMR. LVN C stated they would not look at the original hard copy signed form as they always go into the EMR. LVN C obtained Resident #18's DNR from the EMR. LVN C stated Resident #18's [name of family member] signed the DNR. LVN C stated Resident #18's FM signed the top of the OOH-DNR form by the line labeled agent/medical power of attorney. LVN C stated Resident #18's FM signature is not in the right area at the bottom of the OOH-DNR form. LVN C stated FM signature should be under the guardian/agent/proxy signature. LVN C stated the social worker oversaw DNRs. LVN C stated the form was not a valid DNR due to signature being in the wrong area. LVN C stated a negative outcome of not having a valid DNR was the staff was going to assault the resident because CPR would have to be done without a valid DNR. In an interview on [DATE] at 8:50 AM, LVN D stated BOM oversaw DNRs. LVN D stated DNRs were found either in the binder labeled DNR in the BOM's office or the EMR and it would tell what the resident's code status is. LVN D stated Resident #18 was a DNR. LVN D stated Resident #18's FM signed the OOH-DNR form on [DATE] on line B. LVN D stated FM did not sign on the correct line and should have signed under guardian/agent/proxy, the signature line to the right. LVN D stated the OOH-DNR form was not valid. LVN D stated a negative outcome would be the OOH-DNR form would be invalidated if the form was pulled because LVN D would do CPR without a valid form. In an interview on [DATE] at 8:58 AM, the CN stated the social worker oversaw DNR forms but if not available, the BOM takes over. The CN stated staff would look for advanced directives in the EMR. The CN obtained Resident #18's OOH-DNR form and stated the FM signed where the resident was supposed to sign. The CN stated the form was not a valid DNR. The CN stated a negative outcome would be the DNR would be invalidated and would go against patient wishes. In an interview on [DATE] at 10:27 AM, the BOM stated she assisted as needed without a full-time social worker. BOM stated OOH-DNR forms were stored in the DNR book, and they had been uploaded to the EMR. The BOM stated the FM signed where the resident was supposed to sign. The BOM stated the form was not a valid DNR. The BOM stated a negative outcome would be assuming they would not have had CPR or anything when the resident should have. Record review of OOH-DNR form, undated, revealed in the last section of the form that All persons who have signed above must sign below, acknowledging that this document has bene properly completed. The form contained seven signature lines and included person's signature, guardian/agent/proxy, relative signature, attending physician's signature, second physician's signature, witness 1 signature, witness 2 signature, and notary's signature. Record review of policy Do Not Resuscitate Order, not dated, stated under heading Out of Hospital DNR Form, 5: In all cases the form must be signed and dated according to the guidelines set forth in the form. Record review of facility admission Packet, not dated, under heading Self-Determination End of Life Measures and Advance Directives, stated The Health Care Center agrees to provide resident and or responsible party with the information regarding, second bullet point, valid Advance Directives made in accordance with state law. Record review of website, Texas Health and Human Services Out of Hospital Do Not Resuscitate Program, dated 2026, under Frequently Asked Questions, stated the statute requires that everyone who signed the form MUST sign the form again in the bottom section to acknowledge that the form has been completed.

Based on interview, observation, and record review, the facility failed to ensure all residents were treated with respect and dignity for 1 of 3 residents (Resident #1) reviewed for dignity. The facility failed to ensure LVN A provided privacy during wound care for Resident #1. This failure placed all residents at risk of psychosocial harm due to a diminished quality of life. Finding included: Record review of Resident #1's face sheet undated revealed a [AGE] year-old male with an admission date of 05/30/2024 with the following diagnoses: peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), open wound, cognitive communication deficit (difficulties in communication), traumatic brain injury. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed a BIMS score of 11 which indicated resident's cognition was moderately impaired. During an observation of wound care on 05/28/25 at 03:24 PM, LVN B closed the door, pulled middle curtain and closed window blind. Resident #1 did not have a curtain at foot of bed. Resident #1's roommate was in room during wound care . Resident # 1 was lying in bed with right backside of upper thigh exposed during wound care. During an interview on 05/29/25 at 01:45 PM with LVN B, she stated during wound care they always just close the middle curtain, door, and window blind. She stated she does not know why there was no end privacy curtain. She stated having no curtain at the end of resident's bed would violate resident privacy if the roommate went to the bathroom or someone came in the room. She stated Resident #1's roommate was independent in his wheelchair. She stated Resident #1 was dependent on staff and wound care and ADLs was done in the resident bed. She stated she had been trained to provide resident privacy during wound care. During an interview on 05/29/25 at 02:19 with LVN B, she stated housekeeping had taken down privacy curtains to wash and forgot to put back up. During an interview on 05/29/25 at 03:00 PM with Resident #1, when asked how he would feel if someone saw him during wound care Resident #1 laughed. When asked if he would be embarrassed if someone saw him during wound care Resident #1 stated yes. During an interview on 05/30/25 at 08:48 AM with the DON, she stated privacy should be provided during resident care. She stated all curtains should be pulled. She stated she was not aware of any reason the resident would not have a curtain at the foot of his bed. She stated housekeeping had taken the curtain down to wash and did not put it back up. She stated rooms were monitored daily during champion rounds. She stated champion rounds was department heads make room rounds at least once a day. She stated all staff had been trained to provided resident privacy while providing care. She stated resident was a total care. She stated the potential negative outcome could be resident being exposed to roommate and visitors causing embarrassment. During an interview on 05/30/25 at 09:00 AM with the ADM, he stated privacy should be provided during resident care. He stated the curtain at the foot of Resident #1's bed was taken down by laundry to wash and was not replaced. He stated HSK was responsible for washing and replacing the privacy curtains in resident rooms. He stated rooms were monitored daily during champion rounds. He stated he was not aware Resident #1 did not have a privacy curtain at the foot of his bed. He stated staff were trained on resident privacy during care. He stated the potential negative outcome could cause the resident embarrassment and it was a dignity issue. During an interview on 05/30/25 at 10:45 AM with HSK Supervisor, she stated HSK was responsible to washing and putting the privacy curtains up. She stated resident rooms were monitored daily during champion rounds and she was not aware Resident #1 did not have a privacy curtain at foot of bed. She stated Resident #1 curtain was taken down to wash and was not replaced. She stated the curtain should be replaced when taken down for laundry. She stated there was extra privacy curtains in laundry. She stated privacy curtains were used to provide resident privacy. She stated the potential negative outcome could cause the resident to not have privacy during care . Record review of the facility policy titled Resident Rights dated revised 11/28/2016 revealed the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy . Privacy and confidentiality - the resident has a right to personal privacy and confidentiality of his or her personal and medical records. 1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 2 of 15 residents (Resident #7 and Resident #23) reviewed for PASRR screening, in that: 1. Resident #7 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. 2. Resident #23 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. These failures could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs. The findings included: Resident #7 Record review of Resident #7's electronic face sheet dated 05/29/2025 revealed an [AGE] year-old female initially admitted to the facility on [DATE]. The face sheet included the following diagnoses: Heart Failure, Unspecified, Primary, with an onset date of 03/07/2024. Psychotic disorder with delusions due to known psychological condition (severe mental health disorder that cause abnormal thinking and perceptions), Secondary 2, with an onset date of 04/23/2024. Generalized Anxiety Disorder (excessive, ongoing worry that is hard to control), Secondary, with an onset date of 03/07/2024. Major Depressive Disorder Recurrent, Severe without Psychotic Features (a mood disorder that causes a persistent feeling of sadness and loss of interest), Secondary, with an onset date of 03/07/2024. Dementia in other diseases classified elsewhere, severe, with other behavioral disturbance (loss of mental functions severe enough to affect daily life and activities) Secondary, with an onset date of 03/07/2024. Alzheimer's disease with late onset (common dementia type that develops after age [AGE]), Secondary, with an onset date of 03/07/2024. The document did not indicate Resident #7 had a primary diagnosis of dementia. Record review of Resident #7's Quarterly MDS dated [DATE], revealed under section I, Resident #7 had an active diagnosis of Psychotic Disorder. Additionally, under Section C Cognitive Patterns, Resident #7's MDS revealed a BIMS of 10, indicating the resident was moderately, cognitively impaired. Record review of Resident #7's care plan with a last Care Plan review date of 05/09/2025, under Diagnoses, indicated Resident #7 had a diagnosis of Psychotic Disorder with Delusions Due to Known Psychological Condition and Major Depressive Disorder. Additionally, the care plan included a focus area that began on 03/07/2024 which stated, The resident has mood problem r/t Disease Process of Depression., with a goal that was revised on 03/21/2025 which stated, The resident will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety, or sadness through the review date., with the Interventions/Tasks that included the following: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/07/2024; Assist the resident to identify strengths, positive coping skills and reinforce these. Date Initiated: 03/07/2024; Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 03/07/2024; Educate the resident/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance. Date Initiated: 03/07/2024; Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Date Initiated: 03/07/2024; Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. Date Initiated: 03/07/2024; Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. Record review of Resident #7's physician's Order Summary as of 05/29/2025 revealed under Diagnoses, Major Depressive Disorder Recurrent, Severe Without Psychotic Features and unspecified Psychotic Disorder with Delusions Due to Known Psychological Condition. Resident #7 was prescribed buPROPion HCl ER (hydrochloride extended-release) (XL) Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCl) 1 tablet by mouth one time a day related to Major Depressive Disorder Recurrent, Severe Without Psychotic Features, risperiDONE Oral Tablet 1 MG (Risperidone) 1 tablet by mouth at bedtime related to Major Depressive Disorder Recurrent, Severe Without Psychotic Features and Generalized Anxiety Disorder, and Sertraline HCl (hydrochloride) Oral Capsule 200 MG (Sertraline HCl) 1 capsule by mouth one time a day related to Major Depressive Disorder Recurrent, Severe Without Psychotic Features. Record review of Resident #7's Preadmission Screening and Resident Review (PASRR) Level One (PL1) form dated 03/07/2024 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. There were no additional PL1 screenings provided by the facility for Resident #7. There were no additional documents provided to suggest Resident #7 had a completed PASRR Evaluation. Resident #23 Record review of Resident #23's electronic face sheet dated 05/29/2025 revealed a [AGE] year-old female initially admitted to the facility on [DATE]. The face sheet included the following diagnoses: o Benign neoplasm of meninges, unspecified (non-cancerous, abnormal growth (tumor) that arises from the protective lining around the brain and spinal cord), Primary, with an onset date of 09/10/2024. o Hydrocephalus, Unspecified (buildup of fluid in cavities (ventricles) deep within the brain), Secondary, with an onset date of 09/10/2024. o Personal History of Traumatic Brain Injury, Secondary, with an onset date of 08/20/2024. o Unspecified Mood (affective) Disorder (symptoms that are characteristic of a depressive disorder and cause clinically significant distress or impairment), Secondary, with an onset date of 08/20/2024. The document did not indicate Resident #23 had a primary diagnosis of dementia. Record review of Resident #23's Quarterly MDS dated [DATE], revealed under Section C Cognitive Patterns, Resident #23's MDS revealed a BIMS of 7, indicating the resident was significantly, cognitively impaired. There was not an option on Resident #23's MDS, under section I Psychiatric/Mood Disorder, related to unspecified Mood Disorder. Record review of Resident #23's care plan with a last Care Plan review date of 04/14/2025, under Diagnoses, indicated Resident #23 had a diagnosis of Unspecified Mood (Affective) Disorder. Additionally, the care plan included a focus area that began on 11/13/2024 which stated, Resident is on neuro stimulant for mood disorder, with a goal that was revised on 11/13/2024 which stated, The resident will be free from discomfort or adverse reactions related to neuro stimulant therapy through the review date., with the Interventions/Tasks that included the following: Educate the resident/family/caregivers about the risks, benefits, and the side effects and/or toxic symptoms of neuro stimulant. Date Initiated: 11/13/2024; Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Date Initiated: 11/13/2024. Record review of Resident #23's physician's Order Summary as of 05/29/2025 revealed under Diagnoses Unspecified Mood (Affective) Disorder. Resident #23 was prescribed Sertraline HCl (hydrochloride) Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth at bedtime related to Unspecified Mood (Affective) Disorder. Record review of Resident #23's Preadmission Screening and Resident Review (PASRR) Level One (PL1) form dated 09/20/2014 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. There were no additional PL1 screenings provided by the facility for Resident #23. There were no additional documents provided to suggest Resident #23 had a completed PASRR Evaluation. During an interview on 05/30/2025 at 10:20 AM, RN A stated she was the MDS and PASRR coordinator. RN A stated she was responsible for entering a Rresident's PASRR upon admission. RN A stated she was also responsible for requesting an update if there were any changes needed to a Rresident's PASRR. RN A stated she entered PASRR screenings upon admission, as they were received. RN A stated she did not compare a Resident's diagnoses to the resident's PASRR upon admission, as she assumed the PASRR the facility received was accurate. RN A stated she did not realize this was something she should have done previously. RN A stated she relied on the previously completed PASRR to determine if a Resident had a positive PASRR. RN A stated she would only have submitted a form to request a PASRR to be updated if a Resident had a new diagnosis of a mental illness. RN A stated she thought any diagnosis of dementia would have caused a Resident to have a negative PASRR, and she was not aware the diagnosis of dementia should be the Resident's primary diagnosis to exclude the Resident from a positive PASRR. RN A stated she thought a Resident's diagnosis of mental illness would depend on the severity to determine if the Resident qualified for a positive PASRR. RN A stated Resident #7 did not have a primary diagnosis of dementia, and Resident #7 had a diagnosis of a mental illness. RN A stated, based on that information, Resident #7 should have had a positive PASRR. RN A stated Resident #23 did not have a diagnosis of dementia, and Resident #23 had a diagnosis of mental illness. RN A stated, based on that information, Resident #23 should have had a positive PASRR. RN A stated she believed the reason Resident #7 and Resident #23 did not have a positive PASRR was because they were completed incorrectly prior to the residents being admitted to the facility, and she was not aware she should have requested they be updated. RN A stated she was trained on PASRR via online webinars. RN A stated she would review the PASRR criteria again and request an updated PASRR for Resident #7 and Resident #23, as soon as possible. RN A stated she did not feel Resident #7 or Resident #23 were negatively affected by having an inaccurate PASRR screening since they were being offered psychiatric services. RN A stated if a Resident's PASRR was not accurate, the Resident may not be offered services they could have benefitted from. During an interview on 05/30/2025 at 10:35 AM, the DON stated RN A was responsible for entering a Resident's PASRR, upon admission. The DON stated she was also responsible for reviewing the PASRR prior to admission to ensure the facility was able to meet the needs of the resident. The DON stated RN A should have checked each PASRR for accuracy, and RN A should have requested an updated PASRR if it was not accurate. The DON stated she was unsure of which specific mental illness would have met the criteria for a positive PASRR, and she would need to look it up to verify it. The DON stated, to her knowledge, major depressive disorder, psychotic disorder, and unspecified mood (affective) disorder should have qualified a Resident for a positive PASRR. The DON stated she received training online pertaining to PASRR. The DON stated it was important for a Resident to have an accurate PASRR to ensure the Resident was receiving services related to their mental illness if the Resident wanted services. During an interview on 05/30/2025 at 10:55 AM, the ADM stated RN A was responsible for entering a Resident's PASRR, upon admission. The ADM stated it was his expectation that RN A ensured a Resident's PASRR was accurate based on the Resident's diagnosis. The ADM stated he believed major depressive disorder, psychotic disorder, and unspecified mood (affective) disorder should have qualified a Resident for a positive PASRR. The ADM stated if the PASRR was completed incorrectly prior to admission, it was his expectation the PASRR would be updated as soon as possible after admission. The ADM stated all facility staff received training on PASRR via online webinars. The ADM stated he planned to begin reviewing a resident's PASRR to assist RN A, to ensure each PASRR was accurate. The ADM sated if a resident's PASRR was not accurate, it could affect the care the Resident received, and the Resident may miss services they qualified for. Record review of the facility's policy titled, PASRR Level 1 Screen Policy and Procedure, revised 03/06/2019 revealed the following: Policy: It is the policy of (redacted organization) facilities to obtain a PLI screening form from the RE (referring entity) prior to admission to the NF (nursing facility). Procedure: The Facility will review the PLI Screening Form for completion and correctness prior to admission and submit the PLI form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers and DOB is correct. The Date of the PLI is correct (i.e. correct day, month and year) and review each item on the PLI to ensure accuracy and prevent a regulatory problem.

Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings included: On [DATE] at 8:54AM an initial observation of the kitchen was conducted. Inspection of the freezer revealed: 1 food service bag of frozen chicken quarters with no received date, no open date and open to air, 2 food service bags of frozen chicken quarters with no received date. 1 food service bag of frozen chicken [NAME] with no received date, 7 10-lb. chubs of frozen hamburger meat with no received date, 1 zip seal bag of frozen chicken nuggets no received date, and no open date, 2 3-gal. containers of vanilla ice cream with no received date, and no open date, 1 2.6-lb. frozen apple pie with no received date, no open date and, 1 10-lb. box of frozen sliced carrots with no received date, and no open date, and open to air. Inspection of the refrigerator revealed the following: 2 4-lb. containers of hummus with an expiration date of [DATE], and 1 partial food service bag of shredded mozzarella cheese with no received date, and no open date. Inspection of the dry pantry revealed the following: 1 3-lb. bag of fresh potatoes with no received date, no open date and, open to air, 2 1-lb. bags of powdered sugar with no received date, 2 2-lb. bags of marshmallows with no received date, 5 1-lb. bags of alfredo sauce mix with no received date, 6 2.75-oz. bags of cherry gelatin with no received date, and 1-gal. pancake syrup with no received date or open date. An interview on [DATE] at 9:02 AM with the FSM revealed she was responsible for checking the food items into the kitchen when the truck delivered them to the facility. She stated the negative outcome of not having foods properly labeled and dated was that residents could become sick if they ate foods that are expired. She stated that foods which are not labeled as to what is in the package could cause problems for residents who might be served foods which they should not have. The FSM was asked how she knew when food was to be disposed of and she stated she used the first in/first out method and the expiration date on the product. Record review of the facility's Food Safety policy date 2012 revealed the following: 1. Food is to be tightly wrapped or sealed and covered in a clean container. Opened food shall be labeled, dated, and stored properly. 2. Do not keep potentially hazardous food in the refrigerator past the labeled expiration date. Record review of the facility's Dry Storage policy dated 2012 revealed the following: 1. Dry bulk foods (e.g., flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 2. Open packages of food are stored in closed containers with tight covers, as dated as to when opened. Record review of the facility's Storage Refrigerators policy dated 2012 revealed the following: 1. Food must be covered when stored, with a date label identifying what is in the container. On [DATE] at 9:09AM the FSM stated there was no specific Storage Freezers policy.

Based on interview the facility failed to designate a registered nurse (RN) to serve as the Director of Nurses (DON) on a full-time basis for the care and treatment of 38 out of 38 residents. The facility has been without a full time DON since 12/21/2023. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Findings include: During the Entrance Conference on 03/05/2024 at 9:38 AM, ADM stated the facility did not have a full time DON, but that RN A was doing the job of the DON until they find a replacement. During an interview on 03/05/2024 at 11:25 AM, RN A stated that the facility has not had a DON since 12/21/23, but that she is working as the DON until they find a replacement. RN A stated that she is a compliance nurse for the company that owns the facility. She stated she works in other facilities as well as this one, but that she comes into this facility every morning to check in, but that she does not always work 8 hours a day at this facility. During an interview on 03/05/2024 at 1:26 PM, LVN ADON stated that there is not a DON on staff and that RN A is not the DON. LVN ADON stated that the DON quit around Christmas of last year (2023) and that RN A comes in the mornings and evenings to check on the facility, but only works a couple of days a week. During an interview on 03/05/2024 at 3:07 PM, RN B stated that there is not a full time DON in the facility, but that RN A is at the facility at least once a week. RN B stated a possible negative outcome for not having a full time DON would be that if a resident or family member had an issue, the staff may not be able to help in the situation. During an interview on 03/05/2024 at 3:15 PM, ADM stated that he considers full time to be 8 hours a day, 40 hours per week. ADM stated that RN A is not working in the facility full time and a possible negative outcome for not having a full time DON on staff would be that there would be no oversight for staff. Policy for RN/DON coverage was requested on 03/05/2024 but was not provided by facility.

Based on interview and record review, the facility failed to base on a resident comprehensive assistance to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feedings for 1 of 2 residents (Resident #1). The facility failed to follow physician orders for tube feeding for Resident #1. This deficient practice could place residents at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident # 1's face sheet, dated 4/25/23, revealed a [AGE] year-old female who was admitted to facility on 2/23/22 with diagnoses which included, but were not limited to Cerebral palsy (group of disorders that affect movement and muscle tone or posture), gastrostomy tube (feeding tube), intermittent explosive disorder (explosive eruptions occur, suddenly with little or no warning), urinary tract infection, muscle weakness, developmental disorder of speech and language and constipation (infrequent, irregular or difficult evacuation of the bowels). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 99 which indicated the resident had severely impaired cognition. The MDS revealed the resident required extensive assistance with 2 person assistance with all ADL's. Record review of Resident #1's Care Plan, dated 02/22/23, indicated the resident had a potential fluid deficit related to inability to self-perform nutrition/hydration tasks with PEG (percutaneous endoscopic gastrostomy) feeding/fluid intake. The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Administer fluids per gastrostomy tube as ordered. The resident requires tube feeding r/t Cerebral Palsy. The resident will remain free of side effects or complications related to tube feeding. Check for tube placement and gastric contents/residual volume per facility protocol and record. The resident will maintain adequate nutritional and hydration status and weight stable, no signs or symptoms of malnutrition or dehydration through review date. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. Record review of Resident #1's orders revealed physician orders were Nutren 1.0 Liquid give 500 Milliliter via G-Tube two times a day related to encounter for attention to gastrostomy and every shift flush tube with 60 milliliters water before and after medication and feedings. Nutren 1.0 Liquid give 250 ml via G-Tube one time a day related to encounter for attention to gastrostomy **Hold for residual >200ml** with 100 ml water at 1:00 PM. Start date: 02/23/22 Record review of Resident #1's TAR tube feeding was missed on 3/6/23 at 1300 (1:00pm) and was given at 1730 (5:30 PM). During an interview on 04/25/23 at 11:40 AM with the DON, when asked if the DON failed to give Resident #1 her tube feeding on 3/6/23 at 1:00 pm, she stated, I failed to see it (order for tube feeding). The DON stated this was her first time taking care of Resident #1 and she was new to the facility. The DON stated I was brand new and needed to be trained on the floor, unfortunately that's what happened. The DON stated a negative outcome to the resident could have been weight loss and skin issues. The DON stated I'll admit I made a mistake. Resident #1 failed to receive her tube feeding at 1:00pm on 3/6/23. The facility ensured she got her calories for the day. During an interview on 4/25/23 at 2:37 PM with the ADON when asked how did the DON know she missed the tube feeding at 1:00pm on 3/6/23, she stated I was the one that found the error and notified the DON immediately. The ADON stated she noticed the tube feeding was to be delivered at 1:00 PM and discovered around shift change that the tube feeding had not been given to Resident #1, which was around 5:00 PM. She notified the MD and received an order to give Resident #1 an additional feeding. The ADON stated the resident did receive all her calories for the day, it was just later in the day and into the evening when she received all her caloric intake. Resident #1 receives all caloric intake via gastrostomy tube. Record review of the facility's, undated, policy titled Enteral Nutrition revealed the following: Policy .Adequate nutrition support through enteral nutrition is provided to residents as ordered . Policy Interpretation and Implementation . 4.) Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary . 10.) Enteral feedings are scheduled to try to optimize resident independence whenever possible (for example., at night or during hours that do not interfere with the resident's ability to participate in facility activities.) 11.) The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. Enteral nutrition product . d. Administration method . 13) Staff caring for resident with feeding tubes are trained on potential adverse effects of tube feeding . 17) Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #1) resident reviewed for infection control. CNA B failed to use proper hand hygiene techniques when providing incontinence care for Resident #1. This failure could place residents at risk of being exposed to the spread of viral infections, secondary infections, tissue breakdown, communicable disease and feelings of isolation related to poor hygiene. Findings include: Record Review of Resident # 1's face sheet, dated 4/25/23, revealed a [AGE] year-old female who was admitted to facility on 2/23/22 with diagnoses which included, but were not limited to, Cerebral palsy (group of disorders that affect movement and muscle tone or posture), gastrostomy tube (feeding tube), intermittent explosive disorder (explosive eruptions occur, suddenly with little or no warning), urinary tract infection, muscle weakness, developmental disorder of speech and language and constipation (infrequent, irregular or difficult evacuation of the bowels). Record Review of Resident #1 quarterly MDS, dated [DATE], revealed a BIMS of 99 which indicated severely impaired cognition. The MDS revealed the resident required extensive assistance with 2 persons assistance with all ADL's. Record review of Resident #1 care plan, last reviewed 2/22/23, revealed Resident #1 had bladder and bowel incontinence. Interventions include, but not included: ACTIVITIES: notify nursing if incontinent during activities. INCONTINENT care frequently and apply moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, Monitor/document/report to MD PRN if possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects. Check resident frequently and assist with toileting as needed. Provide peri care after each incontinent episode. Report any skin change to the nurse immediately. During an observation on 4/25/23 at 1:30 PM, CNA A and CNA B assisted Resident #1 with incontinence care. CNA A placed all supplies on the bedside table. CNA A closed the curtains and door for privacy. CNA A and CNA B washed their hands and placed gloves on their hands. CNA B picked up Resident #1, in a scoop lift technique, and placed Resident #1 onto the bed. CNA A and CNA B turned Resident #1 onto each side to remove pants and placed a blanket over her peri-area for privacy. CNA B performed peri-care using wipes from front to back. CNA B took gloves off and placed them into a receptacle. CNA B rolled Resident #1 onto her side and cleaned her anal area from front to back. CNA B removed the dirty brief and threw it away into a receptacle. CNA B picked up gloves and went to place them on and one glove broke. CNA B took the glove off and threw it away. CNA B picked up a new gloves and placed on hands. CNA B did not wash hands or use ABHR prior to applying new gloves. CNA B placed a new brief onto Resident #1 and rolled Resident #1. CNA A and CNA B rolled Resident #1 to each side to pull her pants back into place. CNA B picked up Resident #1 in a scoop lift technique and placed Resident #1 back into her wheelchair. CNA's A and B left Resident #1 in a comfortable position. During an interview on 4/25/23 at 2:31 PM, CNA B stated she did a horrible job with incontinence care. She stated she felt she did 'everything' wrong. CNA B stated I did not sanitize my hands when I changed my gloves. I should have stopped and said I need to stop and sanitize my hands. During an interview on 4/25/23 at 3:04 PM, CNA A stated this was not our best incontinence care. We were always asked to show the state how good we were. CNA A stated she felt like they missed a lot. CNA A stated CNA B did not sanitize her hands when she changed her gloves. Record review of the facility's undated, Nurse Aide Incontinence Care Proficiency Assessment competency revealed Place in employee's personnel file when complete . Washes hands/Changes gloves Record review of the facility's Infection Control Plan: Overview, dated 10/2022, stated .Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection .The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infection and prevent cross-contamination

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated and stored B. Ensure that all expired food is discarded after 7 days. C. Ensure staff followed proper hand hygiene processes. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation in the facility kitchen on [DATE] at 9:23 AM, revealed: [DATE] 09:22AM Entered into kitchen area, observed flat of eggs on grill of stove. Heat coming from stove/oven area. [DATE] 09:23AM observed scrambled, poached eggs left out on roller cart at room temperature. There is also pork sausage stored on same cart at room temperature. Dry cereal in bowls left on counter uncovered. [DATE] 09:24AM Observed tomato juice in a juice cup with lid with no date, tub that juice was in was labeled with a date of [DATE]. [DATE]/,d+[DATE] 09:28AM observed cereal in zip lock bag with a date ,d+[DATE] (No year noted on bag) [DATE] 11:23AM observed expired food in freezer with an expiration date of [DATE]. [DATE] 11:30am observed a bottle scrubber, rag that appeared to be dirty, and a used glove leaning against what appeared to be clean pitchers on a lower shelf in the kitchen. There also appeared to be a mask, and employee personal cup on the top shelf of this unit of shelving. [DATE] 11:44AM Observed what appeared to be a pork chop in a zip-lock bag lying on a cart at room temperature. Unaware of how long product had been there. [DATE] 11:45AM observed cherry cobblers prepared and uncovered on serving trays. Cherry cobblers still uncovered. During an observation of kitchen on [DATE] 09:32am hand washing sink with roll of unused trash bags in the sink as well as on the back of the sink area. This was the only hand washing sink in kitchen During an observation on [DATE] 12:23 PM CNA D wiped brow and played with the miniblind cord. No hand washing or sanitation was performed between the passing of trays. CNA D did not wash or sanitize throughout the delivery of lunch trays. During observation on [DATE] 12:28 PM CNA D assisting resident with eating and did not wash or sanitize hands before assisting resident with eating. CNA D then turned to resident behind her, adjusted clothing protector under residents' hair. CNA D then returned to original resident and did not wash or sanitize hands before assisting resident to eat. During an interview on [DATE] 01:04 PM CNA D stated that we are supposed to sanitize our hands in between each resident's tray. Asked why this was not performed. CNA D stated, I was nervous because you guys were watching us. CAN D was asked what a negative outcome could be from not performing this task, her response was infection or cross contamination. During an interview on [DATE] 02:43pm interviewed Dietary Aide D regarding the warm up of the dishwashing machine. Dietary Aide D stated that it does take some time for the machine to be ready to wash dishes. Dietary Aide D stated that she runs the machine a couple of times before washing any dishes. During an interview on [DATE] at 3:27 PM, Cook C was asked how long food is to be stored in the refrigerators and freezers once they have been opened, she stated that it was to be only 7 days from the date written on the packaging. Also asked if plates and bowls of food were to be set out on trays without coverings, Cook C stated no they should be covered once the plates or bowls are made. When asked why this wasn't done with the dessert Cook C stated that the Dietary Aide D does not normally work with her, and she is not sure why they were not covered. During an interview on [DATE] at 3:38pm, ADM was asked about the hiring of a Dietary Manager. ADM stated that a new one had been hired and was starting the following week. Was unable to interview department manager due to facility not having one. Record review of the facility's policy titled Food Safety with a date of 2012, documented: 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained. 8. Do not keep potentially hazardous food in refrigerator past the labeled expiration date. Record review of the USDA Food Code dated 2017, revealed, in part: Preventing Contamination by Employees ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Record review of facility policy dated 2012 titled Hand Washing revealed the following: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 1. Hand washing occurs in sinks provided for that purpose; sink areas provide hot/cold running water, soap in dispenser, and paper towels, and should have a sign posted conspicuously near or above wash basin. 2. The hand washing technique is as follows: a. Remove ring and watch if they cannot be sanitized during the hand washing process. b. Turn on water, adjusting to warm temperature and forceful flow. c. Wet hands d. Deliver soap in palm e. Lather up soap f. Cup the fingertips within the palms of the hands and rub vigorously g. Interlock fingers and work them back and forth and side to side. h. Scrub back of hands, wrists or lower arms. i. Rinse hands, wrists, and lower arms thoroughly 3. Dry hand sand arms with paper towel, then turnoff the faucets with the paper towel 4. Discard used paper towels in trash receptacle 5. Food preparation sinks are not to be used for hand washing.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #39) of 16 residents reviewed for advanced directives. Resident #39 had a DNR in his record with no date of when the physician signed the document. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Record review of the face sheet dated [DATE] in the clinical record for Resident #39 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include cerebral infarct (occurs as a result of disrupted blood flow to the brain due to problems with the blood that supplies it), metabolic encephalopathy (a problem in the brain that causes a chemical imbalance in the brain), gastrostomy (an opening into the stomach from the abdominal wall made surgically to introduce food), and hemiplegia (paralysis on one side of the body). Record review of the clinical record for Resident #39 revealed the last MDS completed was a quarterly on [DATE] with a BIMS that required staff evaluation because he had memory issues and was unable to complete the test due to memory issues. Resident #39 had a functional status indicating he required one to two-person assistance with all activities. Resident #39 was also listed under section O Special Treatments, Procedures, and Programs to be receiving Hospice care while a resident. Record review of the clinical record for Resident #39's revealed a care plan with admitted [DATE] with the following: Focus: Resident had an order for DNR-date initiated [DATE] Goal: Resident/Responsible party's decision for DNR will be honored .-date initiated [DATE] Intervention-Social Services to consult with resident and representative regarding the decision to continue DNR-date initiated [DATE] Record review of the clinical record for Resident #39's revealed an Order Summary Report with Active Orders as of [DATE] with the following order: Order Summary-DNR Active [DATE] Record review of the clinical record for Resident #39's revealed a DNR (dated [DATE] by the qualified relative) in the miscellaneous section under the Advanced Directives. In the section for the Physicians Statement the physician's signature, printed name, and license number was present but there was no date of when the physician signed the document. Record review of the clinical record for Resident #39 revealed under the miscellaneous section under Hospice Intake was a DNR (dated [DATE] by the qualified relative). This DNR also had no date of when the physician signed the document. During an interview on [DATE] at 08:49 AM LVN A reported that if Resident #39 coded she would first assess the resident to confirm that he had coded and since he was a DNR she would notify the hospice nurse and follow her instructions, that she would not code him, she would not initiate CPR. LVN A reported that she would verify his code status in his hospice book, the facility DNR book, or on the computer system. LVN A checked Resident #39's in the facility's DNR book and found Resident #39's DNR. LVN A reviewed the DNR and reported that it was valid. When asked when the physician signed the DNR LVN A reviewed the DNR again and stated, Oh, it does not have a date of when the doctor signed it. LVN A then reported that Resident #39 did not have a valid DNR and that if Resident #39 coded at this time she would get the crash cart and start CPR. During an interview on [DATE] at 10:06 AM LVN A reported that if a DNR was incorrect then a residents or family's wishes may not be followed, and it could result in a lawsuit. During an interview on [DATE] at 09:21 AM the DON verified that Resident #39 was on hospice and was a DNR. The DON reviewed Resident #39's DNR and reported that it was not valid due to not having a date when the physician signed the DNR. The DON reported that they would get it corrected immediately. The DON reported that an invalid DNR can cause issued if the doctor. did not recognize it as valid DNR once activated, the family could say it was not valid if activated, and it could cause issues with the residents wishes. The DON reported that the part time Social Worker was responsible for reviewing all DNR's for correctness. During an interview by phone on [DATE] at 09:05 AM the Social Worker verified that she was the part time Social Worker for the facility. The Social Worker verified that she would review all DNR's for the facility and that she usually reviews each form line by line and that Resident #39 was one of many and she just missed that the physician did not date the form. The Social Worker reported that an incorrect DNR can result in the resident or family not having their wishes followed. Record review of facility provided policy titled Do Not Resuscitate Order, with the date of revision [DATE], revealed the following: Out of Hospital DNR Form: The Out of Hospital DNR form was designed [NAME] the Texas Department of Human Services to comply with the requirements as set forth in the Health and Safety Code for the purposes of instructing Emergency Medical personnel and other health care professionals for forgo resuscitation attempts. 11. All validly executed DNR order will be honored by the facility 13. For completion of the form, see attached instructions of the out of hospital DNR form the TAHC Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on observation, interview, and record review; it was determined the facility failed to ensure medications were stored in accordance with currently accepted professional principles on 1 (100/500 Hall Medication cart) of 3 medication carts reviewed for medication storage. 5 loose medications were observed in the bottom of the second drawer of the 100/500 Hall medication cart The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could place residents receiving medication at risk for administration of medication incorrectly or missing doses of medications that could result in ineffective treatment and/or exacerbation of the disease process. Findings include: During an observation on 02-23-2023 at 09:41 AM of the 100/500 Hall medication cart 5 loose pills were noted in the bottom of the second drawer. The observation was completed with LVN A present. LVN A was asked by this surveyor to gather all 5 loose pills and have them identified. On 02-23-2023 at 09:57 AM LVN A reported that the 5 loose pills had been identified as Allopurinol (used to treat Gout/high uric acid), Lisinopril (used to treat high blood pressure), Ropinirole (used to treat Parkinson's-a disorder of the central nervous system that affects movement, often including tremors), Carbamazepine (anticonvulsant-used to prevent or reduce the severity of epileptic fits of other convulsions), and Furosemide (Diuretic-used to treat fluid retention). During an interview on 02-23-2023 at 10:02 AM LVN A (the nurse responsible for the 100/500 Hall medication cart this shift) reported that the 5 loose pills were an issue because residents could have a bad reaction to the medications meaning that they could receive the wrong medications if the nurses would not check the back of the pill cards for loose pills that stick and do not get administered. LVN A feels that residents could miss doses of medications and that it could affect their condition. LVN A reported that the nurses are supposed to check their carts every shift, but she got busy this shift and did not have time to check the cart. During an interview on 02-23-2023 at 10:13 AM ADON B verified that she was responsible for checking the carts daily, that she checked them Monday and they were good, that the facility had a call-in Tuesday, and she did not have time due to working the floor, and with the survey she had been busy and did not get to check the carts. ADON B reported that usually she would not find any issues and the five loose pills were abnormal. ADON B did feel that 5 loose pills were an issue and was not acceptable. ADON B reported that the facility would not be aware if the residents received their needed medications. ADON B reported that if a resident did not receive one medication dose it would probably not affect their treatment or care but that the residents do need their medications. ADON B reported that the facility would address the issue of the loose pills. During an interview on 02-24-2023 at 10:08 AM the DON reported that the facility had the night shift check each cart each shift for cleanliness and loose medications and the ADON does an audit of each cart on Mondays and that due to this process this facility does not have any issues with the residents missing any medications, that the five loose pills were a onetime occurrence and that the residents did not miss any doses of medications. The DON reported that this facility has never had any residents report any missed medications and that if the resident's medication were short and needed to be filled early that the facility would pay for the refill but that has not occurred. The DON felt that there were no negative consequences from the loose medications. During an interview on 02-24-2023 at 12:52 PM the DON reported that they only had the one med storage policy that she had provided to this surveyor and did not have any other polices on medication cart safety/care. Record review of the facility provided policy titled Recommended Medication Storage revised 7-2012 revealed no information related to this deficiency.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 16 residents (Resident #30) who were reviewed. The facility failed to maintain elevation of the head of Resident #30's bed as ordered by her physician and indicated in her comprehensive person-centered care plan. This failure could place residents at an increased and unnecessary risk of complications such as aspiration. Findings Include: Record review of Resident #30's face sheet, dated 12/07/2021, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #30's MDS, dated [DATE], revealed that the resident could not participate in a BIMS assessment because she was rarely and/or never understood. The MDS indicated that Resident #30 required extensive assistance from two or more staff with bed mobility, transfers, dressing, eating, and toilet use; and was totally dependent on staff for locomotion and personal hygiene. The MDS indicated that Resident #30 had a feeding tube during the last 7 days prior to the assessment, received 51% or more of her total calories from [MEDICATION(S)] or tube feeding, and received an average fluid intake per day of 501 milliliters or more by IV or tube feeding. The MDS indicated that Resident #30 did not have a [CONDITION(S)] during the last 14 days prior to the assessment. Record review of Resident #30's physician orders, dated 12/07/2021, revealed an active order with a start date of 04/01/2015 that read HOB TO BE AT ATLEAST 30 DEGREES WHILE IN BED [sic]. There was an order with a start date of 04/01/2015 that read [MEDICATION(S)] 1.5 Cal Liquid (Nutritional Supplements) Give 220 milliliter via PEG-Tube every 4 hours for nutrition MAY HOLD FEEDING IF RESIDUAL GREATER THAN 200 ML Give bolus via pump over 1 hour. The resident's dietary order, with a start date of 04/01/2015, read NPO diet NPO texture, NPO consistency. Record review of Resident #30's current comprehensive care plan as of 12/07/2021 revealed the following in part: Focus [Resident #30] has urinary incontinence During Peri Care resident is unable to tolerate lying flat. Resident must have HOB at 30-45 degrees. Goal Maintain HOB at 30-45 degrees during peri care. During an observation on 12/07/2021 at 9:06 AM, CNA A and CNA B performed peri care on Resident #30. Resident #30 had a feeding tube in place but was not currently receiving enteral formula. Resident #30 did not have a [CONDITION(S)] present. During the procedure, CNA A and CNA B laid Resident #30 down flat, without the head of her bed being elevated at all. The head of the resident's bed was flat for about 12 minutes. After completing the peri care, CNA A and CNA B raised the head of Resident # 30's bed, but not to 30 degrees or higher. The elevation of the head of the resident's bed was measured using a protractor application and measured at 16 degrees. During an observation on 12/07/2021 at 9:31 AM, Resident #30 remained in bed and the head of her bed was measured to be elevated at 16 degrees. During an observation on 12/07/2021 at 10:22 AM, Resident #30 remained in bed and the head of her bed was measured to be elevated at 16 degrees. During an observation on 12/07/2021 at 11:01 AM, Resident #30 remained in bed and the head of her bed was measured to be elevated at 16 degrees. During an observation on 12/07/2021 at 12:00 PM, Resident #30 remained in bed and the head of her bed was measured to be elevated at 16 degrees. During an interview on 12/07/2021 at 12:05 PM, CNA A reported that she and CNA B laid the head of Resident #30's bed down flat during peri care but she had been told by nurses that the resident's head was supposed to be elevated. CNA A reported that she was not sure how much the head of Resident #30's bed was supposed to be elevated, and that it should be elevated because the resident used to have a [CONDITION(S)] and still had a feeding tube, therefore she could choke. CNA A reported that she should not have laid Resident #30 that flat. During an interview on 12/07/2021 at 12:14 PM, CNA B reported that she and CNA A laid Resident #30 down felt during peri care so they could more easily roll the resident over onto her side during the procedure and stated, we usually lay her down to roll her over. CNA B reported that she has been told by nurses that the resident's bed is supposed to be reclined up with the head elevated about 45 degrees because the resident has had a [CONDITION(S)] before and sometimes will drool and aspirate. During an interview on 12/07/2021 at 1:56 PM, DON reported that Resident #30 likes to be sitting up. DON reported that Resident #30 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON reported that the resident's orders and care plan information were based on when the resident was receiving continuous feedings by feeding tube, which she no longer receives, and that the facility would be looking to re-evaluate them. DON reported that the resident's physician orders, and care plan were not being followed and that we should always follow physician orders. DON reported that the consequences of not adhering to the resident's orders and care plan could include aspiration and that she did not know why the orders and care plan were not being followed by staff. DON reported that the facility did not currently have a tool with which staff could measure or determine the elevation degree of the heads of resident beds. Record review of facility provided policy titled physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility provided policy titled Comprehensive Care Planning, not dated, revealed in part: The facility will develop and implement a comprehensive person-centered care plan for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality.

Based on interview and record review, it was determined that the facility failed to implement its policies and procedures for prohibition of abuse and neglect related to screening of employees for a history of abuse, neglect or mistreating residents, when they failed to check the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) for 1 of 18 employees ( ADON) annually and 1 of 18 employees (CNA B ) at hire. The employee file of ADON did not have an annual EMR/NAR registry check on file for (YEAR). The employee file of CNA B did not have an EMR/NAR registry check completed at hire. This failure to conduct EMR/NAR checks on employees annually could place all residents of the facility at risk of receiving care from an employee that has a disbarring offense that would preclude them from working in a nursing facility. Findings include: Record review of ADON's personnel file revealed she had a hire date of 11/13/13. The last EMR/NAR search was completed on 6/26/17. Record review of CNA B's personnel file revealed she had a hire date of 9/7/18, The at hire EMR/NAR search was completed on 9/13/18. In an interview on 4/11/19 at 10:52 AM, BOM stated of CNA B's EMR/NAR It was not done at hire. I don't know why. BOM further stated CNA B was in orientation and did not work on the floor until 9/13/18 due to being in orientation. In an interview on 4/11/19 at 1:00 PM, BOM stated of ADON's EMR/NAR It was missed. It was not done for (YEAR). The last EMR/NAR for ADON was done on 6/26/17. Record review of facility provided policy titled Abuse/Neglect, with a revision date of 11/15/16, documents the facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code ,Chapter 250 .All potential employees will be screened for history of abuse, neglect or mistreating of the elderly .The Human Resource Clerk will monitor completeness and status of the criminal history checks . Employees will be screened for abuse by accessing the EMR/NAR. The hiring authority is responsible for training an individual to complete misconduct registry checks on every employee.

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident # 19, and # 45) of 16 Residents reviewed for comprehensive care plans. - The facility failed to implement padded bed rails that were listed as an intervention in Resident #19's comprehensive person-centered care plan. - The facility failed to implement weekly weights that were listed as an intervention in Resident #45's comprehensive person-centered care plan. This failure could affect residents currently in the facility receiving care per comprehensive person-centered care plans resulting in resident no being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident # 19 Record review of Resident #19's clinical record revealed a [AGE] year-old female admitted to the facility initially on 1/25/2019 and readmitted on [DATE]. Resident #19's [DIAGNOSES REDACTED]. Resident #19's last MDS was 2-1-2019 with a BIMS of 4 indicating she is severely cognitively impaired, and that Resident #19 requires 1-2-person assistance with all activities. Further review of Resident #19's clinical record revealed care plans dated 1-26-2019 and 3-13-2019 that stated the following: Focus-The resident uses bed rails to assist with ADLS. Intervention/Tasks-Ensure the rail(s) is padded. During an observation and interview on 04/09/19 at 09:32 AM Resident #19 was noted in a specialized bed in the Trendelenburg position. 1/8th bed rails were noted up on both sides of the bed. No padding was noted on either bed rail. When questioned if she uses the bed rails Resident #19 stated Ya, I use those to make sure I don't fall out of bed. During an observation on 04/10/19 at 02:34 PM Resident #19 was observed in bed playing cards with a staff member. Resident #19's left side bed rails could be observed up with no padding. During an interview on 04/10/19 at 03:33 PM when asked if the Resident #19's bilateral 1/8 bed rails that were up and locked in place during Resident #19's wound care were padded RN C replied, No. There are no pads on her bed rails. We only pad the ones on the chair that she uses. During an interview on 04/11/19 at 11:07 AM when questioned about Resident #19 not having padded bed rails the DON stated, We ordered her a new specialized bed and it didn't come with padded bed rails. We have ordered her padded bed rails and they haven't come in yet. They're due any day. During an interview on 04/11/19 at 01:13 AM the DON stated, We are going to pad her rails with foam until the new rails come in. Resident #45 Record review of Resident #45's clinical record revealed she is a [AGE] year-old female resident admitted to the facility initially on 4-1-2015 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #45's last MDS was a quarterly on 3-11-2019 with a BIMS indicating she is rarely/never understood and could not be evaluated. Resident #45 requires one-two person assistance with all activities. Further record review revealed Resident #45's care plan under the section of Interventions, date of initiation 09/05/2018-Resident #19 noted to have 19 percent weight gain, RD notified and change to [MEDICATION NAME] made. -monitor weight every week and prn. Further record review of Resident #45's clinical record revealed per her Weight Summary that Resident #45 was weighed on 9/7/2018, 10/6/2018, 11/6/2018, 12/7/2018, 1/4/2019, 2/7/2019, 3/8/2019, and 4/5/2019. This indicates Resident #45 was weighed monthly and not weekly as per the comprehensive care plan. During an interview on 04/11/19 at 10:57 AM the ADM stated, Each department is responsible for their part of the care plans. Dietary for nutrition, nursing for nursing, etc. We do a weekly Standards of Care Meeting and discuss each resident and modify their care plans if needed. We will also review all upcoming MDS's to do a complete review of their care plans. When questioned how the staff access care plans the ADM stated, It is on the Kiosk and each staff member has access at any time and should be checking it daily. When questioned if the ADM expects her staff to follow the care plans she stated, Yes I do expect my staff to fallow the care plans and to follow them as written. Record review of facility provided policy titled Comprehensive Care Plans, Nursing Policy & Procedure Manual 2003, dated revised (MONTH) 13, 2007 revealed the following: 4. The comprehensive plan will be reviewed regularly, as per guideline, and/or with significant change and revised by a team of qualified person after each assessment. Documentation will be maintained in the resident clinical record. 5. The care plan will be maintained on the resident clinical record and will be made available to all direct care staff. 8. The comprehensive care plan will be reviewed and signed by the Care Plan team 9. The comprehensive care plan will be reviewed and approved by an RN.

Based on observation, interview and record review, the facility failed to ensure that each resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 1 residents (Resident #45) reviewed for having feeding tubes. - Prior to medication administration for Resident #45, LVN A confirmed placement of the resident's PEG tube (feeding tube) by means of auscultation only, a method that has been deemed ineffective at determining proper feeding tube placement by professional standards of practice. - LVN A administered 3 medications to Resident #45 via PEG tube (feeding tube) in a manner that was not in accordance with accepted professional standards and principles. She crushed the medications into a powder form and put them into the PEG tube during administration without first mixing them with water or another acceptable liquid. This resulted in a temporary clogging of the tube. This failure creates a risk of failing to identify improper tube placement and increases the risk that medications, feeding formula, or other substances put into a feeding tube could be infiltrated or otherwise instilled into a resident's bowels, peritoneal space, or lungs. The failure could ultimately lead to affected residents developing complications such as diarrhea or constipation, nausea and vomiting, dehydration or fluid overload, malnutrition, metabolic imbalances, gastric and/or [MEDICAL CONDITION] infections peritonitis, buried-bumper syndrome, bowel or stomach perforation, and death. Findings Include: Record review of Resident # 45's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 45's quarterly MDS dated [DATE] did not indicate a BIMS score. The MDS indicated that Resident # 45 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. During an observation of medication pass on 04/10/2019 at 9:12 AM, LVN A prepared twelve medications for administration to Resident #45. Each of the medications were placed in a separate medication cup. LVN A prepared them by crushing the tablets into power and emptying the powder out of the capsules into their respective medication cups. LVN A did not label the medication cups or appear to have a system of identifying which medication was in which cup after the medications were prepared. The twelve medications she prepared were as follows: one and a half 400 mg [MEDICATION NAME] tablets, two acidophilus capsules, one 50 mg [MEDICATION NAME] tablets, two 400 mg acetyl l-carnite and 200 mg alpha lipoic acid tablets, one 1 mg [MEDICATION NAME] tablet, one 100 mg [MEDICATION NAME] sodium tablet, two 1 gram sodium chloride tablets, one 10 mg / 325 mg [MEDICATION NAME] tablet, one 20 mg [MEDICATION NAME] tablet, one 5 mg [MEDICATION NAME] tablet, one 10 mg [MEDICATION NAME] tablet, and one 25 mg [MEDICATION NAME] tablet. LVN A placed the prepared medications on a bedside table for administration to Resident #45 via PEG tube. LVN A placed a piston syringe on the PEG tube and listened to the resident's epigastric region with a stethoscope while she injected air through the PEG tube with the syringe. LVN A then placed a piston syringe (without the plunger present) on the end of Resident #45's PEG tube to act as a funnel. LVN A poured the first medication into the PEG tube in powder form without having mixed it with any liquid, then poured a small amount of water in the tube behind it. She repeated this same action for the second medication she put into the tube. The tube ceased to flow and the water she had poured into the tube behind the second medication stayed in the piston syringe. She poured the third medication (also still in powder form) on top of that water in the syringe. Resident #45 moved around a little, and when her abdominal muscles contracted, some air pushed its way out of the PEG tube and bubbled through the water in the piston syringe. When this occurred the powdered medication that was sitting atop the water in the syringe was blown out of the top of the syringe and into the air, creating a small dust cloud of powdered medication. LVN A reacted by repositioning the PEG tube and flushing it with larger amounts of water until it began to flow again. LVN A then mixed the remaining medications with water inside their respective medication cups and continued to administer medications. During an interview with LVN A on 4/10/2019 at 9:30 AM, she reported that she did not feel like she did well administering medications to Resident #45 this morning because she forgot to dilute 3 or 4 of the medications with water in the beginning. LVN A reported that she knew that wasn't right. LVN A claimed she was unable to identify which specific medications were the ones that were administered incorrectly. During an interview with LVN A on 4/10/19 at 9:53 AM, she reported that she checked the placement of Resident #45's PEG tube by auscultating for air prior to administering medications today. LVN A reported that it was the only method of tube placement verification she used. When asked if she was aware, or has ever been told, that air auscultation alone is not an effective method of tube placement verification LVN A reported that she was not aware of that. During an interview with DON on 4/10/19 at 2:36 PM, she reported that her expectations for her staff regarding the verification of PEG tube placement is that they follow policy and procedure on either auscultating or aspirating. DON reported that, to her knowledge, auscultation is an effective method of verifying PEG tube placement. DON reported that she does not consider it to be acceptable practice for staff to put medications in a PEG tube in powder form without first mixing them in a fluid such as water. During an interview with DON on 4/10/19 at 2:48 PM, after she had reviewed the guidance in the State Operations Manual related to feeding tubes, she reported that she planned to start in-servicing her staff soon on properly verifying feeding tube placement. Record review of facility provided policy titled Enteral Medication Administration, dated 01/25/2013, reflected in part: 2. Select and measure, if necessary, each medication to be administered. Tablets and capsules are to be crushed and diluted in a suitable liquid. Liquid preparations should be used whenever possible to avoid plugging the enteral tube. 6. Check placement of tube by aspiration of content or auscultation. Elevate the resident per facility policy. Record review of facility provided policy titled Gastrostomy Tube Care, dated 02/13/2007, reflected in part: Unplug or unclamp the tube and check the placement by aspiration or injecting air and listening to the stomach for sounds. Record review of document published by the Emergency Nurses Association titled Clinical Practice Guideline: Gastric Tube Placement Verification, last revised in (YEAR), reflected in part: Verification of GT placement solely by auscultation, which involves instillation of air into the tube while simultaneously listening with a stethoscope over the epigastric region for the sound of air, is no longer recommended. Multiple studies have demonstrated that using auscultation alone as a GT placement verification method is not reliable (Boeykens, Steeman, & Duysburgh, 2014; Ellett, Croffie, Cohen, & Perkins, 2005; Metheny, Reed, Berglund, & Wehrle, 1994; Yardley & Donaldson, 2010). Pursuit of a reliable, valid, bedside verification method for GT placement has led researchers to investigate alternative methods to auscultation. Record review of article published by the American Association of Critical-Care Nurses titled Feeding Tube Placement, dated 9/15/2016, reflected in part: Nurses should not use the auscultatory (air bolus) or water bubbling method (holding tube under water) to determine tube location. Record review of document by the American Society for [MEDICATION NAME] and Enteral Nutrition's Standards of Practice 2009, National Guidelines Clearinghouse, Abbott Laboratories' Best Practice Guidelines for Tube Feeding titled Best Practice Guidelines for Administering Enteral Nutrition, not dated, reflected in part: The auscultation method of listening for insufflated air over the epigastrum to check for tube placement is not always reliable. Record review of documented by Abbott Laboratories titled Best Practices for Managing Tube Feeding: A Nurse's Pocket Manual, dated (MONTH) (YEAR), reflected in part: C. Bedside verification techniques a. Auscultation Do not rely on auscultation to differentiate among gastric, small bowel, or respiratory tube placement.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 24 Residents (Resident #45) and 5 out of 5 nurses (LVN A, RN C, RN D, ADON, and DON) reviewed for compliance. The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs. - Prior to medication administration for Resident #45, LVN A confirmed placement of the resident's PEG tube (feeding tube) by means of auscultation only, a method that has been deemed ineffective at determining proper feeding tube placement by professional standards of practice. - LVN A administered 3 medications to Resident #45 via PEG tube (feeding tube) in a manner that was not in accordance with accepted professional standards and principles. She crushed the medications into a powder form and put them into the PEG tube during administration without first mixing them with water or another acceptable liquid. This resulted in a temporary clogging of the tube. - Five nurses working at the facility (LVN A, RN C, RN D, ADON, and DON) were interviewed about how to verify feeding tube placement. All five staff members were unaware that verifying feeding tube placement by auscultation of air alone is an ineffective method of determining proper tube placement. This failure has the potential to affect residents by placing them at risk of receiving care from staff that do not possess the knowledge, skills, or competencies necessary to deliver care safely. Findings include: Record review of Resident # 45's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 45's quarterly MDS dated [DATE] did not indicate a BIMS score. The MDS indicated that Resident # 45 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. During an observation of medication pass on 04/10/2019 at 9:12 AM, LVN A prepared twelve medications for administration to Resident #45. Each of the medications were placed in a separate medication cup and LVN A prepared them by crushing the tablets into power and emptying the powder out of the capsules into their respective medication cups. LVN A did not label the medication cups or appear to have a system of identifying which medication was in which cup after the medications were prepared. The twelve medications she prepared were as follows: one and a half 400 mg [MEDICATION NAME] tablets, two acidophilus capsules, one 50 mg [MEDICATION NAME] tablets, two 400 mg acetyl l-carnite and 200 mg alpha lipoic acid tablets, one 1 mg [MEDICATION NAME] tablet, one 100 mg [MEDICATION NAME] sodium tablet, two 1 gram sodium chloride tablets, one 10 mg / 325 mg [MEDICATION NAME] tablet, one 20 mg [MEDICATION NAME] tablet, one 5 mg [MEDICATION NAME] tablet, one 10 mg [MEDICATION NAME] tablet, and one 25 mg [MEDICATION NAME] tablet. LVN A placed the prepared medications on a bedside table for administration to Resident #45 via PEG tube. LVN A placed a piston syringe on the PEG tube and listened to the resident's epigastric region with a stethoscope while she injected air through the PEG tube with the syringe. LVN A then placed a piston syringe (without the plunger present) on the end of Resident #45's PEG tube to act as a funnel. LVN A poured the first medication into the PEG tube in powder form without having mixed it with any liquid, then poured a small amount of water in the tube behind it. She repeated this same action for the second medication she put into the tube. The tube ceased to flow and the water she had poured into the tube behind the second medication stayed in the piston syringe. She poured the third medication (also still in powder form) on top of that water in the syringe. Resident #45 moved around a little, and when her abdominal muscles contracted, some air pushed its way out of the PEG tube and bubbled through the water in the piston syringe. When this occurred the powdered medication that was sitting atop the water in the syringe was blown out of the top of the syringe and into the air, creating a small dust cloud of powdered medication. LVN A reacted by repositioning the PEG tube and flushing it with larger amounts of water until it began to flow again. LVN A then mixed the remaining medications with water inside their respective medication cups and continued to administer medications. During an interview with LVN A on 4/10/2019 at 9:30 AM, she reported that she did not feel like she did well administering medications to Resident #45 this morning because she forgot to dilute 3 or 4 of the medications with water in the beginning. She reported that she knew that wasn't right. LVN A claimed she was unable to identify which specific medications were the ones that were administered incorrectly. During an interview with LVN A on 4/10/19 at 9:53 AM, she reported that she checked the placement of Resident #45's PEG tube by auscultating for air prior to administering medications today. LVN A reported that it was the only method of tube placement verification she used. When asked if she was aware, or has ever been told, that air auscultation alone is not an effective method of tube placement verification she reported that she was not aware of that. During an interview on 4/10/19 at 11:43 AM with RN C, when asked how she would verify tube placement of a feeding tube prior to administering a tube feeding or medication, she reported that she would auscultate the epigastric region while injecting 10 milliliters of air. When asked if auscultation alone is considered an effective method of confirming feeding tube placement, she answered, Yes. During an interview on 4/10/19 at 11:47 AM with RN D, when asked how she would verify feeding tube placement she stated, By auscultating while injecting a little bit of air to make sure you hear gurgles. When asked if auscultation alone is considered an effective method of determining feeding tube placement, she answered, Yes, although we do have to confirm it with an x-ray when it's first put in. During an interview on 4/10/19 at 12:14 PM with ADON, when asked how staff she would verify the placement of a feeding tube prior to the administration of feeding formula or medications, she stated that you could auscultate or check aspirated gastric content. When asked if auscultation alone is an effective method of determining feeding tube placement, she stated, yes. During an interview with DON on 4/10/19 at 2:36 PM, she reported that her expectations for her staff regarding the verification of PEG tube placement is that they follow policy and procedure on either auscultating or aspirating. DON reported that, to her knowledge, auscultation is an effective method of verifying PEG tube placement. DON reported that she does not consider it to be acceptable practice for staff to put medications in a PEG tube in powder form without first mixing them in a fluid such as water. During an interview with DON on 4/10/19 at 2:48 PM, after she had reviewed the guidance in the State Operations Manual related to feeding tubes, she reported that she planned to start in-servicing her staff soon on properly verifying feeding tube placement. During an interview with DON on 4/11/19 at 10:00 AM, she reported that all licensed nursing staff are checked off on feeding tubes during a skills proficiency audit, which all facility nurses are required to complete within 90 days of hire and annually. Record review of facility provided document titled Licensed Nurse Proficiency Audit, not dated, reflected in part: 2. Treatment procedures A. [DEVICE] flushes B. Enteral Feedings Record review of facility provided policy titled Enteral Medication Administration, dated 01/25/2013, reflected in part: 2. Select and measure, if necessary, each medication to be administered. Tablets and capsules are to be crushed and diluted in a suitable liquid. Liquid preparations should be used whenever possible to avoid plugging the enteral tube. 6. Check placement of tube by aspiration of content or auscultation. Elevate the resident per facility policy. Record review of facility provided policy titled Gastrostomy Tube Care, dated 02/13/2007, reflected in part: Unplug or unclamp the tube and check the placement by aspiration or injecting air and listening to the stomach for sounds. Record review of document published by the Emergency Nurses Association titled Clinical Practice Guideline: Gastric Tube Placement Verification, last revised in (YEAR), reflected in part: Verification of GT placement solely by auscultation, which involves instillation of air into the tube while simultaneously listening with a stethoscope over the epigastric region for the sound of air, is no longer recommended. Multiple studies have demonstrated that using auscultation alone as a GT placement verification method is not reliable (Boeykens, Steeman, & Duysburgh, 2014; Ellett, Croffie, Cohen, & Perkins, 2005; Metheny, Reed, Berglund, & Wehrle, 1994; Yardley & Donaldson, 2010). Pursuit of a reliable, valid, bedside verification method for GT placement has led researchers to investigate alternative methods to auscultation. Record review of article published by the American Association of Critical-Care Nurses titled Feeding Tube Placement, dated 9/15/2016, reflected in part: Nurses should not use the auscultatory (air bolus) or water bubbling method (holding tube under water) to determine tube location. Record review of document by the American Society for [MEDICATION NAME] and Enteral Nutrition's Standards of Practice 2009, National Guidelines Clearinghouse, Abbott Laboratories' Best Practice Guidelines for Tube Feeding titled Best Practice Guidelines for Administering Enteral Nutrition, not dated, reflected in part: The auscultation method of listening for insufflated air over the epigastrum to check for tube placement is not always reliable. Record review of documented by Abbott Laboratories titled Best Practices for Managing Tube Feeding: A Nurse's Pocket Manual, dated (MONTH) (YEAR), reflected in part: C. Bedside verification techniques a. Auscultation Do not rely on auscultation to differentiate among gastric, small bowel, or respiratory tube placement.

Based on observation, interview and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The medication error rate was 8 percent with 3 errors out of 36 opportunities involving 1 of 2 staff members (LVN A) and 1 of 6 residents (Resident #45) reviewed for medication administration. - LVN A administered 3 medications to Resident #45 via PEG tube (feeding tube) in a manner that was not in accordance with accepted professional standards and principles. She crushed the medications into a powder form and put them into the PEG tube during administration without first mixing them with water or another acceptable liquid. This failure could place residents at risk of their medications not being administered in accordance with professional standards of practice or physician's orders [REDACTED]. Findings Include: Record review of Resident # 45's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 45's quarterly MDS dated [DATE] did not indicate a BIMS score. The MDS indicated that Resident # 45 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. During an observation of medication pass on 04/10/2019 at 9:12 AM, LVN A prepared twelve medications for administration to Resident #45. Each of the medications were placed in a separate medication cup and LVN A prepared them by crushing the tablets into power and emptying the powder out of the capsules into their respective medication cups. LVN A did not label the medication cups or appear to have a system of identifying which medication was in which cup after the medications were prepared. The twelve medications she prepared were as follows: one and a half 400 mg [MEDICATION NAME] tablets, two acidophilus capsules, one 50 mg [MEDICATION NAME] tablets, two 400 mg acetyl l-carnite and 200 mg alpha lipoic acid tablets, one 1 mg [MEDICATION NAME] tablet, one 100 mg [MEDICATION NAME] sodium tablet, two 1 gram sodium chloride tablets, one 10 mg / 325 mg [MEDICATION NAME] tablet, one 20 mg [MEDICATION NAME] tablet, one 5 mg [MEDICATION NAME] tablet, one 10 mg [MEDICATION NAME] tablet, and one 25 mg [MEDICATION NAME] tablet. LVN A placed the prepared medications on a bedside table for administration to Resident #45 via PEG tube. LVN A placed a piston syringe (without the plunger present) on the end of Resident #45's PEG tube to act as a funnel. LVN A poured the first medication into the PEG tube in powder form without having mixed it with any liquid, then poured a small amount of water in the tube behind it. She repeated this same action for the second medication she put into the tube. The tube ceased to flow and the water she had poured into the tube behind the second medication stayed in the piston syringe. She poured the third medication (also still in powder form) on top of that water in the syringe. Resident #45 moved around a little, and when her abdominal muscles contracted, some air pushed its way out of the PEG tube and bubbled through the water in the piston syringe. When this occurred the powdered medication that was sitting atop the water in the syringe was blown out of the top of the syringe and into the air, creating a small dust cloud of powdered medication. LVN A reacted by repositioning the PEG tube and flushing it with larger amounts of water until it began to flow again. LVN A then mixed the remaining medications with water inside their respective medication cups and continued to administer medications. During an interview with LVN A on 4/10/2019 at 9:30 AM, she reported that she did not feel like she did well administering medications to Resident #45 this morning because she forgot to dilute 3 or 4 of the medications with water in the beginning. She reported that she knew that wasn't right. LVN A claimed she was unable to identify which specific medications were the ones that were administered incorrectly. LVN A did not attempt to readminister the medications because she was not sure what specific medications were administered incorrectly. During an interview with DON on 4/10/2019 at 2:36 PM, she reported that she does not consider it to be acceptable practice for staff to put medications in a PEG tube in powder form without first mixing them in a fluid such as water. Record review of facility provided policy titled Enteral Medication Administration, dated 01/25/2013, reflected in part: 2. Select and measure, if necessary, each medication to be administered. Tablets and capsules are to be crushed and diluted in a suitable liquid. Liquid preparations should be used whenever possible to avoid plugging the enteral tube.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 15 residents reviewed. The facility failed to: Maintain medical information on the MAR/TAR needed to monitor Resident #5 for proper nursing care. Ensure placement of TED hose for Resident # 5 Ensure documentation on the MAR/TAR reflected medications were given as prescribed by the physician for Resident # 5. These failures could affect 4 residents who wear TED hose, 8 residents who receive respiratory treatments(inhalers) and all 58 residents who receive medications and nursing services from the facility by placing them at risk of poor circulation from not wearing the prescribed TED hose, shortness of breath, itching and increased pain and worsening of symptoms related to [DIAGNOSES REDACTED]. The findings were: Record review of Resident # 5's face sheet reflects she is an [AGE] year-old female admitted to the facility on [DATE] with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] documents a BIMS score of 10 out of 15 which indicates moderate cognitive abilities. Care plan dated 3/9/18 documents Resident has [MEDICAL CONDITION] and fluid overload. Resident number 5 requires one to 2 staff to assist with transfers, bed mobility, bathing and dressing. Care plan further documents resident takes [MEDICATION NAME]/ Breo Ellipta. Record review of Consolidated Physician Orders for Resident #5 for (MONTH) and (MONTH) (YEAR) reveal the following medications and orders: TED hose on in a.m. off at p.m. 2 times a day for [MEDICAL CONDITION]. The order status is active. Start date 1/15/18. [MEDICATION NAME] cream 1% apply to the LT topically to time a day for itching. Start date 1/16/18. [MEDICATION NAME] tablet 10-325 MG([MEDICATION NAME]-[MEDICATION NAME]) give one tablet by mouth every 4 hours for pain. Start date 1/15/18. Daily weight one time a day for [MEDICAL CONDITION]. Start date 1/17/18. Record review of the Consolidated Physicians Orders for 1/1/18 - 1/31/18 document: Breo Elipta Aerosol Powder Breath Activated 100-25 MCG/INH 1 puff inhale orally one time a day related to [MEDICAL CONDITION], unspecified Record review of Resident #5 MAR /TAR for 3/1/18 - 3/31/18 revealed Resident #5 missed the following meds and treatments: TED hose were not put on Resident #5 until after 11:30 AM on 3/13/18 and TAR task was not documented on the TAR until after 3:30 pm on 3/13/18. [MEDICATION NAME] tablet 10-325 MG was not given on 1/17/18 at 2000 (8:00pm) or 1/22/18 at 2000 (8:00 PM). Daily weights were not taken on (MONTH) 15,2018, (MONTH) 16, (YEAR) or (MONTH) 29, (YEAR). Weights were not taken on 3/13/18. TED Hose were not placed on Resident #5 on 1/22/18 and 1/31/18 for the 6AM morning time frame. [MEDICATION NAME] cream to bilateral exrememities to be applied 2 times a day was not applied on 1/28/18 or 1/29/18 in the morning. Breo Elipta Aerosol Powder Breath Activated 100-25 MCG/INH 1 puff inhale orally one time a day was not administered on 1/28/18 or 1/29/18 at 8:oo AM related to [MEDICAL CONDITION], unspecified Observation on 3/13/18 at 9:30 AM revealed Resident #5 did not have the TED Hose on her legs. Observation of Resident # 5 on 3/13/18 at 11:15 am revealed Resident #5 did not have her TED hose on her legs. In an interview on 3/13/18 at 11:16 AM Resident #5 stated the staff had not come to put the TED hose on yet. Resident #5 stated in the past she has gone a whole month without them being put on and that she frequently has to remind the staff to put the hose on her. She further said They usually don't put them on me. I have to tell them. In an observation and interview on 3/13/18 at 3:30 pm of Resident #5 it was observed she have TED hose on her legs. Resident #5 stated the staff put the hose on her around lunchtime. In an interview on 3/14/18 at 11:20 AM, LVN A stated if a physician order states TED hose in the AM, it is expected that you put the TED hose on when the resident gets up in the morning. If a physician orders weights every day it is expected to take weights every day. She further stated weights are normally done in the mornings. In an interview on 3/15/18 at 9:10 AM, MED Aide (MA C) stated normally the CNA puts TED hose on first thing in the morning when the resident gets up. Nurses make rounds to make sure this has been done. Nurses round before breakfast. If the hose are not on or the task is not done the nurses will tell the CNA to complete the task. The nurses are to check again and then tell the can to chart it was done once the task has been completed. MA C further stated every morning the CNAs have to go to the resident's room and empty the trash, make the beds and get the residents dressed and put the TED hose on. She further stated staff assist residents with putting the TED hose on even if a resident can do things for themselves. In an interview on 3/15/18 at 9:25 am, LVN Charge Nurse (LVN D) confirmed she is to round every am and check the work of the CNAs including making sure TED hose are put on as per the physician orders. LVN D confirmed she goes around behind the CNAs and checks the work. LVN D stated she writes in the resident chart whether the task is completed. She stated if a TED hose was refused, the TAR documentation would have a #2 and a circle around it. When asked about Resident #5's Ted Hose she stated she put them on Resident #5 at 11:30 on 3/13/18 and that she documented in the chart after she put them on the resident. She stated she is aware that a task needs to be documented right when it is done. She further stated a restorative aide does weights for Resident #5 and then gives the list to the nurse and the weights are transferred to the residents chart daily. In an interview on 3/15/18 at 9:35 AM, Restorative Aide (RA E) stated she does weights for 3 residents including Resident #5. RA E stated she weighs the residents in the mornings and then gives the weights to the nurses to transfer into the chart. RA E stated if she does not get the weights done she tells the nurses and they are to do the weights. She stated if she does not get them done it is because she has to go on a transport or help on the floor. She stated this frequently happens. RA E stated she did not get Resident #5's weights on 3/12/18 or 3/13/18. RA E further stated she did not take Resident #5 weights from 2/26/18 to (MONTH) 3, (YEAR). She stated she did not know if they were done on those days or not. In an interview and a review of the MAR and TAR for Resident #5 on 3/15/18 at 10:40 am, LVN F stated CMAs can give a resident [MEDICATION NAME] if they get the nurse assess the resident first. LVN F stated the staff are expected to fill out the MAR and TAR right then. Refusals are circled on the front of the MAR and TAR. LVN F reviewed the MAR and TAR for Resident # 5 and stated I don't know why it is not filled out. It should have been filled out when they gave it. In an interview and a review of Resident #5 MAR and TAR on 3/15/18 at 10:45 am, DON stated the nurses do administer the [MEDICATION NAME] medication, the inhalers and creams. The CMAs do the medications and the [MEDICATION NAME] if it is a scheduled medication. When asked about when she expects staff to document a medication and a task from the physician orders she said she expects them to document right then. DON stated if a task or medication is refused she expects the MAR and TAR to have a circle with an R on the front of the MAR and TAR. DON further agreed it should have been filled out at the time it was done and doesn't know why it was not filled out. In an interview on 3/15/18 at 1:15 PM, CNA H confirmed CNAs are to assist residents with TED hose when they get the residents up in the mornings and assist them to get dressed. She said residents are assisted to dress when they get up before they go to breakfast. CNA H confirmed this includes TED hose and that staff are to document what is done when you do it. In an interview on 3/16/18 at 9:25 am, Physician G confirmed he is the primary physician for Resident #5 and stated occasionally the facility has not followed his orders and also on one or two occasions there have been miscommunications with following his orders. Physician G confirmed he had ordered Breo Elipta Aerosol Powder and has not stopped the order or changed it as far as he can recall. Physician G stated if it is not on her green physician order papers it is possible the insurance would not pay for it and the orders should reflect that and been changed. He stated he does not recall being told insurance would not pay for any prescribed meds and cannot recall being contacted by the facility for any different medications. Physician G further stated he had just signed off on the most recent orders. In an interview on 3/16/18 at 9:35 am, with LVN F, surveyor requested the order for the Breo Elipta Aerosol Powder or a physician order stating it was discontinued. Surveyor requested information to be faxed to the office of surveyor. On 3/16/18 at 11:39 am fax received for copy of physician order dated 1/14/18 for [MEDICATION NAME] 80-4.5 Mco -inhaler- 1 puff, BID for 90 days. Record Review of the facility policy titled 'Medication Administration Procedures' dated 2003 revealed the following: 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medications be charted immediately after administration, but if the facility policy permits, medication may be charted immediately before administration. Initials are to be used. Checkmarks are not acceptable. All nurses administering medication must sign an initial the designated area of each residents' medication/treatment administration record or resident specific master signature log for identification of all initials used in charting. 6. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurse's notes section of the medication administration record. 11. All current medications and dosage schedules are to be listed on the resident's current medication administration record. Record Review of the facility policy titled 'Physicians Orders' dated (MONTH) updated 6/22/15 documents: Physician's monthly consolidated orders must be reviewed by licensed nurse to assure they reflect all current workers. Any orders not within the monthly physician's order must be added before physician review or being sent for physician signature. Physician's paper orders must be printed monthly on pastel green paper. The physician must approve, sign, return the monthly consolidated orders within 30 days the original paper monthly orders should be returned to placed on the chart within 30 days. The facility's CMS 672, Resident Census and Condition of Residents, dated 3/13/18 reflects a census of 58 residents with 4 residents that wear TED Hose and 8 residents who receive respiratory treatments.

Based on observation, interview and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and medical records for 1 of 58 residents (Resident #20); in that: Resident #20's personal health and care information was left displayed on an unattended kiosk in Hall 6. This deficient practice could result in resident personal information being exposed to unauthorized individuals and has the potential to affect all 58 residents. Findings include: Observation on 3/12/18 at 02:12 PM, revealed an unlocked kiosk display, unattended in Hall 6 with Resident #20's personal information visible to anyone walking down the hall. During an interview on 03/15/18 at 09:15 AM, DON stated that CNAs document in resident care plan and documentation on the kiosk. She confirmed that they are to log off if they walk away. During an interview on 03/15/18 at 10:38 AM, CNA B stated that every time they are logged in and leave they have to exit out. Record review of an undated document titled Privacy Notice under Our legal duty: We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice. Record review of document titled Resident Rights: Privacy and confidentiality - the resident has a right to personal privacy and confidentiality of his or her personal and medical records. Record review of an undated document titled Policy Disclosure of Personal Health Information and P[NAME] Kiosk Documentation: 4) Staff is instructed to log off of the software after each use. The facility's CMS 672, Resident Census and Condition of Residents, dated 3/13/18 reflects a census of 58 residents.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit mistreatment and neglect for 6 of 10 Residents, whom reside in the secure unit, (Residents #1, #19, #23, #24, #25, and #27) that were reviewed for neglect when; 1. The facility failed to supervise Resident #1 when she had 12 falls (10 un-witnessed) in the secure unit of the facility over a 3 month time frame. The last fall occurred while she was not being supervised by any facility staff and resulted in a [MEDICAL CONDITION] that had to be surgically repaired. The one staff member on duty the day that Resident #1 experienced a fall with fracture (CNAK) had gone to the bathroom and did not call for any assistance from other staff to supervise the residents while she was in the restroom which is the procedure of the facility according to the DON. 2.. The facility failed to incorporate changes in staffing patterns in the secured unit when there were an additional 7 falls (3 un-witnessed) by 5 different residents (Residents #19, #23, #24, #25, and #27) in the secure unit of the facility during this three month time frame. The facility failed to staff the secure unit with sufficient staff to meet the requirements outlined in the MDS and care plans for the 10 residents residing in the secure unit, that required more supervision related to the residents fall risk, behaviors, and increased need for assistance with activities of daily living. 3. The facility failed to incorporate the interventions included in the resident's care plans to prevent falls for Residents #1, #19, #23, #24, #25, and #27, and all suffered falls while residing in the secure unit. These failures resulted in identification of an IJ (Immediate Jeopardy) on 3/25/15. While the immediacy of the IJ was removed on 3/26/15, the facility remained out of compliance at a severity level of harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to adequately supervise the ten residents in the secure unit to prevent falls led to Resident #1 having a fall with fracture that required surgical intervention. This failure also affected the 5 residents (Residents #19, #23, #24, #25, and #27) that experienced falls; and could possibly affect the additional 4 residents that reside in the secure unit by placing them at risk for falls with major injury due to lack of supervision. Findings include: Resident #1: Record review of Resident #1's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #1's clinical record revealed that there was no care plan in place prior to the first fall. A fall risk assessment was performed on 12/9/14 at the time of the first fall and indicated that Resident #1 was at a low risk for falls. Record review indicates that Resident #1 had her first fall, which was unwitnessed and the resident was found next to the bed, on the night of admission on 12/9/14. The incident report states that the facility will place a bed pressure alarm. Review of incident reports shows a second unwitnessed fall, where the resident was found next to the wheelchair, for Resident #1 on 12/15/14. The incident report indicates that frequent monitoring will be initiated after this fall, and no care plan was initiated. A fall risk assessment was performed on 12/15/14 at the time of the fall and indicated that Resident #1 was at a low risk for falls. The next incident report indicating a witnessed fall (fall #3) was on 12/23/14. Interventions listed on the incident report state chair alarm and frequent monitoring. Once again no care plan was initiated. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. The incident report for fall #4 on 12/28/14 stated that the interventions initiated after the fall will include bed and chair alarms and a low bed. It also stated they will continue frequent monitoring which is not included on the interventions on the fall care plan. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the facility's fall care plan initiated on 12/28/14, after Resident #1 experienced the 4th fall (witnessed) stated the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Review of the incident report for the 5th fall, which was unwitnessed and the resident was found next to her wheelchair, on 12/29/14 includes interventions of body alarm, pressure alarms, and low bed. It also stated, "Instructed CNA to do hourly rounds and make sure that the bed is in low position and the alarms are on if in bed or chair. The care plan was not updated to include the intervention of hourly rounds. On 12/30/14 there was no incident report for a fall; however, an intervention of adding a drop seat to the wheelchair was added to the fall care plan for Resident #1. A fall risk assessment was performed on 12/30/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 6th fall, which was unwitnessed and the resident fell from her wheelchair, on 1/1/15 stated that the chair alarm will be re-initiated. The Fall Care Plan dated 12/30/14 was updated at this time to include, "Educate staff to stay with resident while in wheelchair." A fall risk assessment was performed on 1/1/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 7th fall on 1/18/15, which was unwitnessed has no new interventions listed on the report; however, the care plan was updated to include every 2 hour monitoring. A fall risk assessment was performed on 1/18/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 8th fall on 2/2/15, which was unwitnessed states that the aide did not hear the alarm go off and the the resident was found on the floor close to the bathroom doorway. The report includes the new intervention: "Educate all staff of importance of alarms." A fall risk assessment was performed on 2/2/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. There was a new care plan for falls for Resident #1 started on 2/2/15 that lists the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Drop seat in wheelchair Every two hour toileting program PT (physical therapy) referral Please note the interventions are no longer in place to: 1. Instructed the CNA to do hourly rounds and make sure the bed is in low position and the alarms are on if in bed or chair. 2. Monitor resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair Review of the incident report for the 9th fall on 2/6/15, which was unwitnessed and no alarm was heard by the CNA on duty where the resident was found in the corner next to the closet, states to add anti-slip socks, which was not added to the resident's fall care plan. Resident #1 had a laceration on her back from this fall. A fall risk assessment was performed on 2/6/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident for the 10th fall on 2/27/15 at 12:00 p.m., which was unwitnessed and the resident was found on the floor, includes the intervention of collect urine sample for confusion, which was added to the care plan. A fall risk assessment was performed on 2/27/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 11th fall on 2/27/15 at 2:30 a.m., which was unwitnessed and the resident was found on the floor next to her bed, has the following interventions listed: "ensured all alarms working monitor frequently." Frequent monitoring is not on the current Fall Care Plan for Resident #1. Review of the incident report for the 12th fall on 3/15/15, which was unwitnessed and the resident was found in the floor between the hallway and the dining room, has no new interventions. The resident was transported by ambulance to the emergency room and had surgical intervention for a [MEDICAL CONDITION]. A fall risk assessment was performed on 3/15/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. A third Fall Care Plan was put into place at this time and the only interventions listed on this third care plan are as follows: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Encourage the resident to use appropriate footwear Encourage use of call light Bed Alarm Chair Alarm Toileting Program Low Bed Floor Mat Please note the interventions are no longer in place to: 1. Monitor the resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair 4. Drop seat in wheelchair 5. Scoop Mattress 6. Physical Therapy referral Record review of the Quarterly MDS dated [DATE] showed that Resident #1 had a BIMS score of 2 (severely impaired) and required extensive assistance with two people for transfer, bathing, and dressing. Resident #1 needed extensive assistance from one person to assist for eating and hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of bladder. Record review of the fall risk assessment for Resident #1 on 3-15-15 showed a score of 20 (high risk for falls). Review of the facility investigation report stated on 3-15-15 at 4:30 p.m. Resident #1 sustained a fall in the secure unit of the facility, 911 was called and Resident #1 was transferred to the emergency room , where an x-ray revealed she had a fractured left hip. Resident #1 then was sent to the hospital for surgical hip repair. The facility investigation report completed by the ADM and dated 3-16-15 stated that " All residents of the secure unit were in the dining room waiting for supper to be served. Resident #1 was the second to last resident that was brought in the dining room. CNA was getting the last resident up with the help of another aide. The other aide had just left and the CNA on the unit was completing her tasks with the last resident when she heard Resident #1's chair alarm going off and immediately went to investigate, but the resident was already on the floor." The investigation written report statement provided by CNA K (the CNA in the secure unit at the time of the fall) dated 3-15-15 stated that "Resident #1 was sitting in the dining room in a chair with her alarm under her and activated. I went into the bathroom and when I heard her alarm go off, I rushed out of the bathroom and found Resident #1 on the ground in the doorway of the dining room complaining that her hip was hurting. I pulled an emergency light and waited with her until help arrived." During an interview with the ADM on 3-24-15 at 4:30 p.m. when asked about the fall with Resident #1 she stated,Resident #1 was on the secure unit and she was in the dining room in a wheel chair with the alarm on. She had a [MEDICAL CONDITION]; she is constantly trying to get up. The aide was helping Resident # 19 into her chair and the floater had left, I don't know the aides name that remained on the unit. She heard the alarm, went over to the dining room and Resident #1 was already on the floor. She obviously had a fracture, she was left on the floor and 911 was called. She went to the hospital with a [MEDICAL CONDITION]." An interview with CNA K on 3-25-15 at 5:15 p.m. revealed that CNA K was working on the secure unit the afternoon that Resident #1 fell . CNA K stated; "I was working as a CNA on the secure unit. I was the only one there, Resident #1 wanted to sit in a regular chair. I put the chair alarm on the regular chair and Resident #1 sat down, then I went to the bathroom. I heard the alarm and when I came out Resident #1 was on the floor." CNA K stated she stays back in the secure unit and the only time she has another person in the secure unit is if she calls for help. CNA K was asked if she felt she should have called for help when she needed to go to the restroom she stated, "Resident #1 seemed fine, but maybe I should have called for help." CNA K stated there is always only one aide in the secure unit unless they need help. Observation on 3-24-15 at 12:00 p.m. revealed Resident #1 sitting in a geri chair in the dining room of the secure unit. There was no chair alarm or personal alarm on Resident #1's person or chair. The care plan dated 3/15/15 stated that the resident should have a chair alarm. Record review of the additional incident and accident reports for the secure unit revealed that there were 7 additional falls for a total of 19 falls over a four month period in the secure unit from 11-16-15 through 3-15-15 for 5 different residents. Resident #19: Record review of Resident #19 (who resides in the secure unit) medical record revealed an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #19 needed extensive assistance and 2 people for transfers, and dressing. For bathing Resident #19 was totally dependent with one person. Resident #19 is frequently incontinent of bowel and bladder. Resident #19's BIMS score was 3 (severely impaired). Review of the fall risk assessment for Resident #19 on 3-25-15 showed a score of 19 (high risk for falls). Review of Event Nurses Notes (Incident Report) for Resident #19 dated 1/20/15 revealed a witnessed fall. The facility intervention initiated after the fall: vitals and shoes/slip socks. Review of Event Nurses Notes for Resident #19 dated 1/21/15 revealed an un-witnessed fall. The facility intervention initiated after the fall: Pressure alarm (Bed), and encouraged resident to use call light for assist. Review of Event Nurses Notes for Resident #19 dated 2/27/15 revealed a witnessed fall. The report form contained a check box labeled other which was checked, but did not have any interventions written in. Resident #19's care plan dated 1/21/15 showed she is a high risk for falls. Interventions listed for Resident #19 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #19's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; Encourage use of call light and other: staff to anticipate resident needs 2/27/15. Review of Resident #19's Falls Care Plan dated 1/20/15 revealed the facility did not do a fall risk assessment after each fall on 1/20/15 and 1/21/15. Resident #23: Record review of Resident #23's (who resides in the secure unit) medical record stated Resident #23 is an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the annual MDS assessment dated [DATE] showed that Resident #23 needed supervision and set up help for transfer, and eating. Resident #23 needed limited assistance with one person for eating, and dressing. Resident #23 needed physical help with one person for bathing. Resident #23's BIMS score was 2 (severely impaired). Review of the fall risk assessment for Resident #23 on 3-19-15 showed a score of 10 (high risk for falls). Review of Event Nurses Notes dated 12/15/14 revealed an un-witnessed fall. Obstacles noted: blanket/walker. Facility interventions initiated after the fall: monitor regularly and take to the bathroom every 2 hours. Resident #23's care plan showed she is a high risk for falls. Interventions listed for Resident #23 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #23's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; anticipate resident needs 12/15/14. Review of Resident #23's fall care plan dated 12/15/14 revealed the facility did not ensure Resident #23's room was free from clutter as attested in the event nurses note on 12/15/14 that listed a blanket and walker as obstacles. Resident #24: Record review of Resident #24 (who resides in the secure unit) revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the quarterly MDS dated [DATE] showed that Resident #24 needed extensive assistance with two people for transfer, and dressing. Resident #24 needed extensive assistance with one person for eating and bathing. Resident #24's BIMS score was 00. Resident #24 was frequently incontinent of bowel and bladder. Review of the fall risk assessment for Resident #24 on 1-16-15 showed a score of 14 (high risk for falls). Review of an Event Nurses Note dated 1/16/15 revealed an un-witnessed fall. Obstacles involved; roommates wheelchair. Facility interventions initiated after the fall;low bed, house shoes and non-skid socks. The narrative stated that the roommates wheelchair was left in the way and this is what Resident #24 fell on . Resident #24's care plan dated 1/16/15 showed Resident #24 is a high risk for falls. Interventions listed for Resident #24 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #24's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; other - remove obstacles in room [ROOM NUMBER]/16/15. Review of Resident #24's fall care plan revealed obstacles were not removed from Resident #24's room until after a fall occurred. Resident #25: Record Review of Resident #25 (who resides in the secure unit) revealed that Resident #25 is a [AGE] year old with the following Diagnoses: [REDACTED]. Review of the fall risk assessment for Resident #25 on 1-16-15 showed a score of 20 (high risk for falls). Review of an Event Nurses Note dated 12/14/14 revealed a witnessed fall. No facility initiated interventions after the event were checked. Review of a Nurses Note - Fall (no date on form) for Resident #25 revealed approaches taken by the facility; Body alarm for bed and chair, low bed and wheelchair. Resident #25's care plan dated 12/14/14 showed Resident #25 is a high risk for falls. Interventions listed for Resident #25 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #25's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #25's fall care plan revealed the facility did not perform a fall risk assessment after the 12/14/14 fall. Review of the quarterly MDS dated [DATE] revealed that Resident #25 needed extensive assistance with one person for transfer, and eating. Resident #25 needed extensive assistance with 2 people for dressing. Resident #25 was totally dependent with one person for bathing. Resident #25 is always incontinent of bladder and frequently incontinent of bowel. Resident #25's BIMS score is 3 (severely impaired). Resident #27: Record review of Resident #27's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated that Resident #27 requires extensive assistance with one person for transfer, dressing, eating and total dependence with two people for bathing. Resident #27 is always incontinent of urine and frequently incontinent of bowel. Resident #2's BIMS score is 3 (severely impaired). Review of Resident #27's Fall Risk assessment dated [DATE] revealed a score of 10 (high risk for falls). Review of an Event Nurses Note dated 12/4/14 revealed a witnessed fall. There were no interventions initiated by the facility after the fall. Resident #27's care plan dated 12/4/14 showed Resident #27 is a high risk for falls. Interventions listed for Resident #27 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #27's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #27's fall care plan revealed the facility did not perform a fall risk assessment after the 12/4/14 fall. There were 2 additional fall risk assessments done on 1/19/15 and 3/19/15 that scored Resident #27 a 9 (low risk for falls). During an interview with the DON on 3-25-15 at 4:00 p.m. she was asked about the staffing in the secure unit in regards to falls, she stated there was one CNA on the unit both day and night. They have a float that usually goes back every hour to check in the secure unit. The CNA on the secure unit will call for help if needed. The DON stated she felt like it was adequately staffed. During an interview with the DON on 3-26-15 at 2:35 p.m. the DON was asked about CNA K leaving Resident #1 unattended, and the DON stated that CNA K should not have left Resident #1 unattended. "Our procedure is to call for another staff to come and cover when we go to the bathroom." Review of the staffing sheet for the secure unit showed for March 1 through March 25 there were 14 days with a CNA assigned to float and 7 days where there was not a float assigned at all. On 5 days there was only partial coverage, there was not a float assigned for the entire shift. During an interview in the secure unit with CNA F on 3-25-14 at 3:10 p.m. she stated she works the 2:00 p.m. to 10:00 p.m. shift. "It is always just myself working with all the residents here. If anyone needs assistance, it leaves everyone else by themselves." During an interview with LVN E on 3-25-15 at 7:00 p.m. she was asked how many aides are in the secure unit, LVN E stated that only one aide works in the secure unit. LVN E said "I stay at the main nurse's station and I pass meds for the secure unit and Hall #6." LVN E works the 6:00 p.m. to 6:00 a.m. shift. During an interview with HA on 3-25-15 at 6:50 p.m. when asked if he worked in the secure unit HA stated. "I pass ice; I don't provide any personal care." During an interview with CNA L on 3-25-15 at 6:55 p.m. CNA L stated, "I work the 2:00 p.m. to 10:00 p.m. shift in the secure unit. We have a float and they help if needed." Review of the facility's policy and procedure for Abuse/Neglect dated 1-8-2003 stated: 6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Identification: 6. The Task G Coordinator and/or administrator will conduct a thorough investigation of the incident. F. Protection: The QA committee will analyze Abuse and Neglect policies/procedures following an investigation or at least quarterly to determine if changes to the policy and procedure need to be made. Review of the facility provided policy and procedure for Preventive Strategies to Reduce Fall Risks dated 5-20-2011 stated: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. 12. Nursing Care: Maintain regular toileting schedules, Place confused Residents close to the nurse's station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. 13. Use bed/chair alarms systems to monitor unsafe activity as needed. Review of the policy and Procedure provided by the facility for Secure Care Environment Staffing Requirements stated: The Secure Care Environment will provide therapeutic staffing to meet the distinct needs of residents with wandering and dementia related disorders. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of the residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the Secure Care Environment. Policy: 1. The Secure Care environment will employ licensed nurses and certified nurse's aides for direct patient care. The Secure Environment will be staffed to meet the needs of each resident. The facility Administrator was notified on 3/25/15 at 5:50 p.m. that an IJ situation had been identified due to the above failures. The facility's Plan of Removal was provided by the Administrator on 3/26/15 at 10:50 am. The Plan of Removal was accepted at 11:11 a.m. on 3/26/15. The facility took the following actions to remove the immediacy of the IJ: 1. Two staff members will be on the secure unit for each of the three shifts; with 2 staff members on the secure unit at all times - one staff member can also be sent to notify the charge nurse if extra intervention is needed. 2. The staff will be immediately in-serviced on how to reach the nurse when needed i.e. phone call to the desk, intercom to page a nurse to the secure unit, and walkie-talkies for communication with the nurse assigned to the secured unit. 3. All staff that work on the secure unit will be in-serviced before they start their next shift on: a. falls and fall prevention b. how to care for a resident with a hip injury i.e. turning and transfers c. verbal and non-verbal pain indications and pain assessments 4. All residents in the secured unit and the rest of the facility will be assessed for pain immediately on 3/26/15, and pain management will be initiated if needed per physician orders. All residents will have a pain assessment performed upon admission, quarterly, with a significant change, and upon resident complaint of pain. 5. All residents will have the current Fall Risk Assessment reviews and updated as needed on 3/26/15, and care plans will be updated. 6. Residents with multiple falls will have new interventions considered and implemented of appropriate as the care plan is updated as needed. (See attached Event Nurses Note). 7. The DON will review all incidents to make sure appropriate interventions are updated and in place, as well as care plans updated as needed. 8. A review of the last 30 days of event notes of falls will be completed to check that the appropriate interventions are in place. 9. The plan will be reviewed by the QAPI committee weekly for 4 weeks, and then monthly for 90 days. Observations on 3/26/15 at 1:40 p.m. and 4:00 p.m. showed that the locked unit was staffed with two staff members. One of the two CNA's in the unit carried a walkie-talkie. The LVN assigned to the unit (who is not present on the unit unless needed) was also wearing a walkie-talkie for communication with the CNA located inside the secure unit. Review of staff in-service records show that 56 staff members were in-serviced on two staff in secure unit at all times, falls, fall prevention, pain assessments and non-verbal signs of pain, and repositioning and transferring of residents with recent [MEDICAL CONDITION] on 3/25/15 and 3/26/15 by the ADON. Review of the in-service provided by the PT on 3/26/15 on the transfers and care specific to the post [MEDICAL CONDITION] resident was attended by 45 staff members. Interviews with 12 different staff members from 1:15 p.m. to 1:40 p.m. on 3/26/15 revealed that they had been in-serviced on the above. In an additional interview with CNA O on 3/26/15 at 4:00 p.m. it was stated that the aide would attend an in-service presented by the PT that afternoon. Record review of the pain assessments of each of the ten residents residing in the secured unit show the assessments were all completed on 3/25/15. Record review of the fall assessments for each of the ten residents in the secured unit were completed on 3/26/15. On 3/26/15 at 11:11 a.m. the CA and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of pattern that is not immediate jeopardy die to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. The CMS Resident Census and Condition of Residents obtained on 3-24-15 documented a Census of 84. There were 10 residents residing in the secured unit and six of these residents were at high risk for falls.

Based on observation, interview and record review the facility failed to ensure that each resident receives adequate supervision to prevent accidents for 6 of 10 Residents (Resident's #1, #19, #23, #24, #25, and #27) reviewed for accidents and supervision. 1. The facility failed to ensure that CNA K followed the procedure to call for assistance to the secure unit when CNA K left the 10 residents unattended to go to the restroom. Resident #1, who had a history of [REDACTED]. Resident #1 was in the secured unit dining room sitting in a dining room chair when she was left unsupervised. 2. The facility failed to staff the secure unit with sufficient staff to meet the requirements outlined in the MDS and care plans for the 10 residents residing in the secure unit, that required more supervision related to the residents fall risk, behaviors, and increased need for assistance with activities of daily living. The facility failed to change staffing patterns in the secured unit when there were an additional 7 falls (3 un-witnessed) by 5 different residents (Residents #19, #23, #24, #25, and #27), who were all at high risk for falls, in the secure unit of the facility during this three month time frame. These failures resulted in identification of an IJ (Immediate Jeopardy) on 3/25/15. While the immediacy of the IJ was removed on 3/26/15, the facility remained out of compliance at a severity level of harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to adequately supervise the 10 residents in the secure unit to prevent falls affected Resident #1 when she had a fall with fracture that required surgical intervention. The failure also affected the 6 residents that had falls, and could affect the remaining 4 residents that reside in the secure unit by placing them at risk for falls with major injury. Findings include: Resident #1: Record review of Resident #1's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #1's clinical record revealed that there was no care plan in place prior to the first fall. A fall risk assessment was performed on 12/9/14 at the time of the first fall and indicated that Resident #1 was at a low risk for falls. Record review indicates that Resident #1 had her first fall, which was unwitnessed and the resident was found next to the bed, on the night of admission on 12/9/14. The incident report states that the facility will place a bed pressure alarm. Review of incident reports shows a second unwitnessed fall, where the resident was found next to the wheelchair, for Resident #1 on 12/15/14. The incident report indicates that frequent monitoring will be initiated after this fall, and no care plan was initiated. A fall risk assessment was performed on 12/15/14 at the time of the fall and indicated that Resident #1 was at a low risk for falls. The next incident report indicating a witnessed fall (fall #3) was on 12/23/14. Interventions listed on the incident report state chair alarm and frequent monitoring. Once again no care plan was initiated. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. The incident report for fall #4 on 12/28/14 stated that the interventions initiated after the fall will include bed and chair alarms and a low bed. It also stated they will continue frequent monitoring which is not included on the interventions on the fall care plan. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the facility's fall care plan initiated on 12/28/14, after Resident #1 experienced the 4th fall (witnessed) stated the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Review of the incident report for the 5th fall, which was unwitnessed and the resident was found next to her wheelchair, on 12/29/14 includes interventions of body alarm, pressure alarms, and low bed. It also stated, "Instructed CNA to do hourly rounds and make sure that the bed is in low position and the alarms are on if in bed or chair. The care plan was not updated to include the intervention of hourly rounds. On 12/30/14 there was no incident report for a fall; however, an intervention of adding a drop seat to the wheelchair was added to the fall care plan for Resident #1. A fall risk assessment was performed on 12/30/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 6th fall, which was unwitnessed and the resident fell from her wheelchair, on 1/1/15 stated that the chair alarm will be re-initiated. The Fall Care Plan dated 12/30/14 was updated at this time to include, "Educate staff to stay with resident while in wheelchair." A fall risk assessment was performed on 1/1/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 7th fall on 1/18/15, which was unwitnessed has no new interventions listed on the report; however, the care plan was updated to include every 2 hour monitoring. A fall risk assessment was performed on 1/18/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 8th fall on 2/2/15, which was unwitnessed states that the aide did not hear the alarm go off and the the resident was found on the floor close to the bathroom doorway. The report includes the new intervention: "Educate all staff of importance of alarms." A fall risk assessment was performed on 2/2/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. There was a new care plan for falls for Resident #1 started on 2/2/15 that lists the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Drop seat in wheelchair Every two hour toileting program PT (physical therapy) referral Please note the interventions are no longer in place to: 1. Instructed the CNA to do hourly rounds and make sure the bed is in low position and the alarms are on if in bed or chair. 2. Monitor resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair Review of the incident report for the 9th fall on 2/6/15, which was unwitnessed and no alarm was heard by the CNA on duty where the resident was found in the corner next to the closet, states to add anti-slip socks, which was not added to the resident's fall care plan. Resident #1 had a laceration on her back from this fall. A fall risk assessment was performed on 2/6/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident for the 10th fall on 2/27/15 at 12:00 p.m., which was unwitnessed and the resident was found on the floor, includes the intervention of collect urine sample for confusion, which was added to the care plan. A fall risk assessment was performed on 2/27/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 11th fall on 2/27/15 at 2:30 a.m., which was unwitnessed and the resident was found on the floor next to her bed, has the following interventions listed: "ensured all alarms working monitor frequently." Frequent monitoring is not on the current Fall Care Plan for Resident #1. Review of the incident report for the 12th fall on 3/15/15, which was unwitnessed and the resident was found in the floor between the hallway and the dining room, has no new interventions. The resident was transported by ambulance to the emergency room and had surgical intervention for a fractured hip. A fall risk assessment was performed on 3/15/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. A third Fall Care Plan was put into place at this time and the only interventions listed on this third care plan are as follows: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Encourage the resident to use appropriate footwear Encourage use of call light Bed Alarm Chair Alarm Toileting Program Low Bed Floor Mat Please note the interventions are no longer in place to: 1. Monitor the resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair 4. Drop seat in wheelchair 5. Scoop Mattress 6. Physical Therapy referral Record review of the Quarterly MDS dated [DATE] showed that Resident #1 had a BIMS score of 2 (severely impaired) and required extensive assistance with two people for transfer, bathing, and dressing. Resident #1 needed extensive assistance from one person to assist for eating and hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of bladder. Record review of the fall risk assessment for Resident #1 on 3-15-15 showed a score of 20 (high risk for falls). Review of the facility investigation report stated on 3-15-15 at 4:30 p.m. Resident #1 sustained a fall in the secure unit of the facility, 911 was called and Resident #1 was transferred to the emergency room , where an x-ray revealed she had a fractured left hip. Resident #1 then was sent to the hospital for surgical hip repair. The facility investigation report completed by the ADM and dated 3-16-15 stated that " All residents of the secure unit were in the dining room waiting for supper to be served. Resident #1 was the second to last resident that was brought in the dining room. CNA was getting the last resident up with the help of another aide. The other aide had just left and the CNA on the unit was completing her tasks with the last resident when she heard Resident #1's chair alarm going off and immediately went to investigate, but the resident was already on the floor." The investigation written report statement provided by CNA K (the CNA in the secure unit at the time of the fall) dated 3-15-15 stated that "Resident #1 was sitting in the dining room in a chair with her alarm under her and activated. I went into the bathroom and when I heard her alarm go off, I rushed out of the bathroom and found Resident #1 on the ground in the doorway of the dining room complaining that her hip was hurting. I pulled an emergency light and waited with her until help arrived." During an interview with the ADM on 3-24-15 at 4:30 p.m. when asked about the fall with Resident #1 she stated,Resident #1 was on the secure unit and she was in the dining room in a wheel chair with the alarm on. She had a brain injury; she is constantly trying to get up. The aide was helping Resident # 19 into her chair and the floater had left, I don't know the aides name that remained on the unit. She heard the alarm, went over to the dining room and Resident #1 was already on the floor. She obviously had a fracture, she was left on the floor and 911 was called. She went to the hospital with a hip fracture." An interview with CNA K on 3-25-15 at 5:15 p.m. revealed that CNA K was working on the secure unit the afternoon that Resident #1 fell . CNA K stated; "I was working as a CNA on the secure unit. I was the only one there, Resident #1 wanted to sit in a regular chair. I put the chair alarm on the regular chair and Resident #1 sat down, then I went to the bathroom. I heard the alarm and when I came out Resident #1 was on the floor." CNA K stated she stays back in the secure unit and the only time she has another person in the secure unit is if she calls for help. CNA K was asked if she felt she should have called for help when she needed to go to the restroom she stated, "Resident #1 seemed fine, but maybe I should have called for help." CNA K stated there is always only one aide in the secure unit unless they need help. Observation on 3-24-15 at 12:00 p.m. revealed Resident #1 sitting in a geri chair in the dining room of the secure unit. There was no chair alarm or personal alarm on Resident #1's person or chair. The care plan dated 3/15/15 stated that the resident should have a chair alarm. Record review of the additional incident and accident reports for the secure unit revealed that there were 7 additional falls from 5 other residents; for a total of 19 falls over a four month period in the secure unit from 11-16-15 through 3-15-15. Resident #19: Record review of Resident #19 (who resides in the secure unit) medical record revealed an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #19 needed extensive assistance and 2 people for transfers, and dressing. For bathing Resident #19 was totally dependent with one person. Resident #19 is frequently incontinent of bowel and bladder. Resident #19's BIMS score was 3 (severely impaired). Review of the fall risk assessment for Resident #19 on 3-25-15 showed a score of 19 (high risk for falls). Review of Event Nurses Notes (Incident Report) for Resident #19 dated 1/20/15 revealed a witnessed fall. The facility intervention initiated after the fall: vitals and shoes/slip socks. Review of Event Nurses Notes for Resident #19 dated 1/21/15 revealed an un-witnessed fall. The facility intervention initiated after the fall: Pressure alarm (Bed), and encouraged resident to use call light for assist. Review of Event Nurses Notes for Resident #19 dated 2/27/15 revealed a witnessed fall. The report form contained a check box labeled other which was checked, but did not have any interventions written in. Resident #19's care plan dated 1/21/15 showed she is a high risk for falls. Interventions listed for Resident #19 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #19's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; Encourage use of call light and other: staff to anticipate resident needs 2/27/15. Review of Resident #19's Falls Care Plan dated 1/20/15 revealed the facility did not do a fall risk assessment after each fall on 1/20/15 and 1/21/15. Resident #23: Record review of Resident #23's (who resides in the secure unit) medical record stated Resident #23 is an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the annual MDS assessment dated [DATE] showed that Resident #23 needed supervision and set up help for transfer, and eating. Resident #23 needed limited assistance with one person for eating, and dressing. Resident #23 needed physical help with one person for bathing. Resident #23's BIMS score was 2 (severely impaired). Review of the fall risk assessment for Resident #23 on 3-19-15 showed a score of 10 (high risk for falls). Review of Event Nurses Notes dated 12/15/14 revealed an un-witnessed fall. Obstacles noted: blanket/walker. Facility interventions initiated after the fall: monitor regularly and take to the bathroom every 2 hours. Resident #23's care plan showed she is a high risk for falls. Interventions listed for Resident #23 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #23's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; anticipate resident needs 12/15/14. Review of Resident #23's fall care plan dated 12/15/14 revealed the facility did not ensure Resident #23's room was free from clutter as attested in the event nurses note on 12/15/14 that listed a blanket and walker as obstacles. Resident #24: Record review of Resident #24 (who resides in the secure unit) revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the quarterly MDS dated [DATE] showed that Resident #24 needed extensive assistance with two people for transfer, and dressing. Resident #24 needed extensive assistance with one person for eating and bathing. Resident #24's BIMS score was 00. Resident #24 was frequently incontinent of bowel and bladder. Review of the fall risk assessment for Resident #24 on 1-16-15 showed a score of 14 (high risk for falls). Review of an Event Nurses Note dated 1/16/15 revealed an un-witnessed fall. Obstacles involved; roommates wheelchair. Facility interventions initiated after the fall;low bed, house shoes and non-skid socks. The narrative stated that the roommates wheelchair was left in the way and this is what Resident #24 fell on . Resident #24's care plan dated 1/16/15 showed Resident #24 is a high risk for falls. Interventions listed for Resident #24 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #24's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; other - remove obstacles in room 1/16/15. Review of Resident #24's fall care plan revealed obstacles were not removed from Resident #24's room until after a fall occurred. Resident #25: Record Review of Resident #25 (who resides in the secure unit) revealed that Resident #25 is a [AGE] year old with the following Diagnoses: [REDACTED]. Review of the fall risk assessment for Resident #25 on 1-16-15 showed a score of 20 (high risk for falls). Review of an Event Nurses Note dated 12/14/14 revealed a witnessed fall. No facility initiated interventions after the event were checked. Review of a Nurses Note - Fall (no date on form) for Resident #25 revealed approaches taken by the facility; Body alarm for bed and chair, low bed and wheelchair. Resident #25's care plan dated 12/14/14 showed Resident #25 is a high risk for falls. Interventions listed for Resident #25 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #25's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #25's fall care plan revealed the facility did not perform a fall risk assessment after the 12/14/14 fall. Review of the quarterly MDS dated [DATE] revealed that Resident #25 needed extensive assistance with one person for transfer, and eating. Resident #25 needed extensive assistance with 2 people for dressing. Resident #25 was totally dependent with one person for bathing. Resident #25 is always incontinent of bladder and frequently incontinent of bowel. Resident #25's BIMS score is 3 (severely impaired). Resident #27: Record review of Resident #27's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated that Resident #27 requires extensive assistance with one person for transfer, dressing, eating and total dependence with two people for bathing. Resident #27 is always incontinent of urine and frequently incontinent of bowel. Resident #2's BIMS score is 3 (severely impaired). Review of Resident #27's Fall Risk assessment dated [DATE] revealed a score of 10 (high risk for falls). Review of an Event Nurses Note dated 12/4/14 revealed a witnessed fall. There were no interventions initiated by the facility after the fall. Resident #27's care plan dated 12/4/14 showed Resident #27 is a high risk for falls. Interventions listed for Resident #27 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #27's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #27's fall care plan revealed the facility did not perform a fall risk assessment after the 12/4/14 fall. There were 2 additional fall risk assessments done on 1/19/15 and 3/19/15 that scored Resident #27 a 9 (low risk for falls). During an interview with the DON on 3-25-15 at 4:00 p.m. she was asked about the staffing in the secure unit in regards to falls, she stated there was one CNA on the unit both day and night. We have a float that usually goes back every hour to check in the secure unit. The CNA on the secure unit will call for help if needed. The DON stated she felt like it was adequately staffed. During an interview with the DON on 3-26-15 at 2:35 p.m. the DON was asked about CNA K leaving Resident #1 unattended, and the DON stated that CNA K should not have left Resident #1 unattended. "Our procedure is to call for another staff to come and cover when we go to the bathroom." Review of the staffing sheet for the secure unit showed for March 1 through March 25 there were 14 days with a CNA assigned to float and 7 days where there was not a float assigned at all. On 5 days there was only partial coverage, there was not a float assigned for the entire shift. During a confidential interview on 3-25-15 at 11:10 a.m. Interviewee stated there is only one aide on the secure unit at any time and that is not enough for the type of people they are caring for and how many people they are caring for. The Interviewee stated the nurse did not stay in the secure unit during evening. During an interview in the secure unit with CNA F on 3-25-15 at 3:10 p.m. she stated she works the 2:00 p.m. to 10:00 p.m. shift. "It is always just myself working with all the residents here. If anyone needs assistance, it leaves everyone else by themselves." During an interview with LVN E on 3-25-15 at 7:00 p.m. she was asked how many aides are in the secure unit, LVN E stated that only one aide works in the secure unit. LVN E said "I stay at the main nurse's station and I pass meds for the secured unit and Hall #6." During an interview with HA on 3-25-15 at 6:50 p.m. when was asked if he worked in the secure unit HA stated "I pass ice; I don't provide any personal care." During an interview with CNA L on 3-25-15 at 6:55 p.m. CNA L stated, "I work the 2:00 p.m. to 10:00 p.m. shift in the secure unit. We have a float and they help if needed." Review of the facility provided policy and procedure for Preventive Strategies to Reduce Fall Risks dated 5-20-2011 stated: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. 12. Nursing Care: Maintain regular toileting schedules, Place confused Residents close to the nurse's station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. 13. Use bed/chair alarms systems to monitor unsafe activity as needed. Review of the policy and Procedure provided by the facility for Secure Care Environment Staffing Requirements stated: The Secure Care Environment will provide therapeutic staffing to meet the distinct needs of residents with wandering and dementia related disorders. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of the residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the Secure Care Environment. Policy: 1. The Secure Care environment will employ licensed nurses and certified nurse's aides for direct patient care. The Secure Environment will be staffed to meet the needs of each resident. The facility Administrator was notified on 3/25/15 at 5:50 p.m. that an IJ situation had been identified die to the above failures. The facility's Plan of Removal was provided by the Administrator on 3/26/15 at 10:50 am. The Plan of Removal was accepted at 11:11 a.m. on 3/26/15. The facility took the following actions to remove the immediacy of the IJ: 1. Two staff members will be on the secure unit for each of the three shifts; with 2 staff members on the secure unit at all times - one staff member can also be sent to notify the charge nurse if extra intervention is needed. 2. The staff will be immediately in-serviced on how to reach the nurse when needed i.e. phone call to the desk, intercom to page a nurse to the secure unit, and walkie-talkies for communication with the nurse assigned to the secured unit. 3. All staff that work on the secure unit will be in-serviced before they start their next shift on: a. falls and fall prevention b. how to care for a resident with a hip injury i.e. turning and transfers c. verbal and non-verbal pain indications and pain assessments 4. All residents in the secured unit and the rest of the facility will be assessed for pain immediately on 3/26/15, and pain management will be initiated if needed per physician orders. All residents will have a pain assessment performed upon admission, quarterly, with a significant change, and upon resident complaint of pain. 5. All residents will have the current Fall Risk Assessment reviews and updated as needed on 3/26/15, and care plans will be updated. 6. Residents with multiple falls will have new interventions considered and implemented as appropriate as the care plan is updated as needed. (See attached Event Nurses Note). 7. The DON will review all incidents to make sure appropriate interventions are updated and in place, as well as care plans updated as needed. 8. A review of the last 30 days of event notes of falls will be completed to check that the appropriate interventions are in place. 9. The plan will be reviewed by the QAPI committee weekly for 4 weeks, and then monthly for 90 days. Observations on 3/26/15 at 1:40 p.m. and 4:00 p.m. showed that the locked unit was staffed with two staff members. One of the two CNA's in the unit carried a walkie-talkie. The LVN assigned to the unit (who is not present on the unit unless needed) was also wearing a walkie-talkie for communication with the CNA located inside the secure unit. Review of staff in-service records show that 56 staff members were in-serviced on two staff in secure unit at all times, falls, fall prevention, pain assessments and non-verbal signs of pain, and repositioning and transferring of residents with recent hip fracture on 3/25/15 and 3/26/15 by the ADON. Review of the in-service provided by the PT on 3/26/15 on the transfers and care specific to the post hip fracture resident was attended by 45 staff members. Interviews with 12 different staff members from 1:15 p.m. to 1:40 p.m. on 3/26/15 revealed that they had been in-serviced on the above. In an additional interview with CNA O on 3/26/15 at 4:00 p.m. it was stated that the aide would attend an in-service presented by the PT that afternoon. Record review of the fall assessments for each of the ten residents in the secured unit were completed on 3/26/15. On 3/26/15 at 11:11 a.m. the CA and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of pattern that is not immediate jeopardy die to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. The CMS Resident Census and Condition of Residents obtained on 3-24-15 documented a Census of 84. There were 10 residents residing in the secured unit and six of these residents were at high risk for falls.

Based on observation, interview and record review it was determined the facility failed to have sufficient nursing staff in the secure unit to provide nursing and related services for 6 of 10 Residents, whom reside in the secure unit, (Residents #1, #19, #23, #24, #25, and #27) reviewed to maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to provide adequate staff in the secured unit that had 10 Residents at high risk for falls. - Resident #1 had 12 falls over a three month time frame, the last one resulting in a [MEDICAL CONDITION]. -5 Additional Residents (Residents #19, #23, #24, #25, and #27) had falls totaling 7 falls in a three month time frame. These failures resulted in identification of an IJ (Immediate Jeopardy) on 3/25/15. While the IJ was removed on 3/26/15, the facility remains out of compliance at a severity of harm that is not immediate jeopardy, and a scope of isolated; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place The facility's failure to provide sufficient staff to provide the necessary supervision could result affect all 10 residents in the secure unit by placing them at risk for falls with major injury due to lack of staff supervision. Findings include: Resident #1: Record review of Resident #1's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #1's clinical record revealed that there was no care plan in place prior to the first fall. A fall risk assessment was performed on 12/9/14 at the time of the first fall and indicated that Resident #1 was at a low risk for falls. Record review indicates that Resident #1 had her first fall, which was unwitnessed and the resident was found next to the bed, on the night of admission on 12/9/14. The incident report states that the facility will place a bed pressure alarm. Review of incident reports shows a second unwitnessed fall, where the resident was found next to the wheelchair, for Resident #1 on 12/15/14. The incident report indicates that frequent monitoring will be initiated after this fall, and no care plan was initiated. A fall risk assessment was performed on 12/15/14 at the time of the fall and indicated that Resident #1 was at a low risk for falls. The next incident report indicating a witnessed fall (fall #3) was on 12/23/14. Interventions listed on the incident report state chair alarm and frequent monitoring. Once again no care plan was initiated. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. The incident report for fall #4 on 12/28/14 stated that the interventions initiated after the fall will include bed and chair alarms and a low bed. It also stated they will continue frequent monitoring which is not included on the interventions on the fall care plan. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the facility's fall care plan initiated on 12/28/14, after Resident #1 experienced the 4th fall (witnessed) stated the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Review of the incident report for the 5th fall, which was unwitnessed and the resident was found next to her wheelchair, on 12/29/14 includes interventions of body alarm, pressure alarms, and low bed. It also stated, "Instructed CNA to do hourly rounds and make sure that the bed is in low position and the alarms are on if in bed or chair. The care plan was not updated to include the intervention of hourly rounds. On 12/30/14 there was no incident report for a fall; however, an intervention of adding a drop seat to the wheelchair was added to the fall care plan for Resident #1. A fall risk assessment was performed on 12/30/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 6th fall, which was unwitnessed and the resident fell from her wheelchair, on 1/1/15 stated that the chair alarm will be re-initiated. The Fall Care Plan dated 12/30/14 was updated at this time to include, "Educate staff to stay with resident while in wheelchair." A fall risk assessment was performed on 1/1/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 7th fall on 1/18/15, which was unwitnessed has no new interventions listed on the report; however, the care plan was updated to include every 2 hour monitoring. A fall risk assessment was performed on 1/18/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 8th fall on 2/2/15, which was unwitnessed states that the aide did not hear the alarm go off and the the resident was found on the floor close to the bathroom doorway. The report includes the new intervention: "Educate all staff of importance of alarms." A fall risk assessment was performed on 2/2/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. There was a new care plan for falls for Resident #1 started on 2/2/15 that lists the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Drop seat in wheelchair Every two hour toileting program PT (physical therapy) referral Please note the interventions are no longer in place to: 1. Instructed the CNA to do hourly rounds and make sure the bed is in low position and the alarms are on if in bed or chair. 2. Monitor resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair Review of the incident report for the 9th fall on 2/6/15, which was unwitnessed and no alarm was heard by the CNA on duty where the resident was found in the corner next to the closet, states to add anti-slip socks, which was not added to the resident's fall care plan. Resident #1 had a laceration on her back from this fall. A fall risk assessment was performed on 2/6/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident for the 10th fall on 2/27/15 at 12:00 p.m., which was unwitnessed and the resident was found on the floor, includes the intervention of collect urine sample for confusion, which was added to the care plan. A fall risk assessment was performed on 2/27/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 11th fall on 2/27/15 at 2:30 a.m., which was unwitnessed and the resident was found on the floor next to her bed, has the following interventions listed: "ensured all alarms working monitor frequently." Frequent monitoring is not on the current Fall Care Plan for Resident #1. Review of the incident report for the 12th fall on 3/15/15, which was unwitnessed and the resident was found in the floor between the hallway and the dining room, has no new interventions. The resident was transported by ambulance to the emergency room and had surgical intervention for a [MEDICAL CONDITION]. A fall risk assessment was performed on 3/15/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. A third Fall Care Plan was put into place at this time and the only interventions listed on this third care plan are as follows: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Encourage the resident to use appropriate footwear Encourage use of call light Bed Alarm Chair Alarm Toileting Program Low Bed Floor Mat Please note the interventions are no longer in place to: 1. Monitor the resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair 4. Drop seat in wheelchair 5. Scoop Mattress 6. Physical Therapy referral Record review of the Quarterly MDS dated [DATE] showed that Resident #1 had a BIMS score of 2 (severely impaired) and required extensive assistance with two people for transfer, bathing, and dressing. Resident #1 needed extensive assistance from one person to assist for eating and hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of bladder. Record review of the fall risk assessment for Resident #1 on 3-15-15 showed a score of 20 (high risk for falls). Review of the facility investigation report stated on 3-15-15 at 4:30 p.m. Resident #1 sustained a fall in the secure unit of the facility, 911 was called and Resident #1 was transferred to the emergency room , where an x-ray revealed she had a fractured left hip. Resident #1 then was sent to the hospital for surgical hip repair. The facility investigation report completed by the ADM and dated 3-16-15 stated that " All residents of the secure unit were in the dining room waiting for supper to be served. Resident #1 was the second to last resident that was brought in the dining room. CNA was getting the last resident up with the help of another aide. The other aide had just left and the CNA on the unit was completing her tasks with the last resident when she heard Resident #1's chair alarm going off and immediately went to investigate, but the resident was already on the floor." The investigation written report statement provided by CNA K (the CNA in the secure unit at the time of the fall) dated 3-15-15 stated that "Resident #1 was sitting in the dining room in a chair with her alarm under her and activated. I went into the bathroom and when I heard her alarm go off, I rushed out of the bathroom and found Resident #1 on the ground in the doorway of the dining room complaining that her hip was hurting. I pulled an emergency light and waited with her until help arrived." During an interview with the ADM on 3-24-15 at 4:30 p.m. when asked about the fall with Resident #1 she stated,Resident #1 was on the secure unit and she was in the dining room in a wheel chair with the alarm on. She had a [MEDICAL CONDITION]; she is constantly trying to get up. The aide was helping Resident # 19 into her chair and the floater had left, I don't know the aides name that remained on the unit. She heard the alarm, went over to the dining room and Resident #1 was already on the floor. She obviously had a fracture, she was left on the floor and 911 was called. She went to the hospital with a [MEDICAL CONDITION]." An interview with CNA K on 3-25-15 at 5:15 p.m. revealed that CNA K was working on the secure unit the afternoon that Resident #1 fell . CNA K stated; "I was working as a CNA on the secure unit. I was the only one there, Resident #1 wanted to sit in a regular chair. I put the chair alarm on the regular chair and Resident #1 sat down, then I went to the bathroom. I heard the alarm and when I came out Resident #1 was on the floor." CNA K stated she stays back in the secure unit and the only time she has another person in the secure unit is if she calls for help. CNA K was asked if she felt she should have called for help when she needed to go to the restroom she stated, "Resident #1 seemed fine, but maybe I should have called for help." CNA K stated there is always only one aide in the secure unit unless they need help. Observation on 3-24-15 at 12:00 p.m. revealed Resident #1 sitting in a geri chair in the dining room of the secure unit. There was no chair alarm or personal alarm on Resident #1's person or chair. The care plan dated 3/15/15 stated that the resident should have a chair alarm. Observation of the secure unit on Hall 3 revealed, it is separated by locking double doors that are at the entrance to the secure unit and entrance is by key pad only. There is no nurses station in the locked unit. The common/dining area where residents and staff congregate is at the far end of the hall with all resident rooms between it and the double doors separating it from the rest of the facility. The nurses station (located outside the locked unit) is in the center of the facility with a tall counter around it and the other halls extending out like spokes in a wheel. With only one aide in attendance in the secured unit for 10 residents, it is a significant distance from the entrance to the unit and the area where residents usually stay. A call for help from the common/dining room of the secure unit would be difficult to hear by anyone outside the secure unit because of the distance involved. Record review of the additional incident and accident reports for the secure unit revealed that there were 7 additional falls for a total of 19 falls over a four month period in the secure unit from 11-16-15 through 3-15-15. Review of the additional nine residents in the secure unit: Record review of Resident #18 (who resides in the secure unit) medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed that Resident #18 needed extensive supervision with one person for transfer, dressing, bathing, and eating. Resident #18 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #18's BIMS score was 3 (severely impaired). Record review of Resident #19 (who resides in the secure unit) medical record revealed an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #19 needed extensive assistance and 2 people for transfers, and dressing. For bathing Resident #19 was totally dependent with one person. Resident #19 is frequently incontinent of bowel and bladder. Resident #19's BIMS score was 3 (severely impaired). Review of the fall risk assessment for Resident #19 on 3-25-15 showed a score of 19 (high risk for falls). Review of Event Nurses Notes (Incident Report) for Resident #19 dated 1/20/15 revealed a witnessed fall. The facility intervention initiated after the fall: vitals and shoes/slip socks. Review of Event Nurses Notes for Resident #19 dated 1/21/15 revealed an un-witnessed fall. The facility intervention initiated after the fall: Pressure alarm (Bed), and encouraged resident to use call light for assist. Review of Event Nurses Notes for Resident #19 dated 2/27/15 revealed a witnessed fall. The report form contained a check box labeled other which was checked, but did not have any interventions written in. Resident #19's care plan dated 1/20/15 showed she is a high risk for falls. Interventions listed for Resident #19 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #19's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; Encourage use of call light and other: staff to anticipate resident needs 2/27/15. Review of Resident #19's Falls Care Plan revealed the facility did not do a fall risk assessment after each fall on 1/20/15 and 1/21/15. Record review of Resident #20 (who resides in the secure unit) stated that Resident #20 was [AGE] years of age admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated Resident #20 needed extensive assistance with 2 people for transfer and dressing. Resident #20 was totally dependent with 2 people for bathing. Resident #20 was always incontinent of bowel and bladder. Resident #20's BIMS score was 3 (severely impaired). Record review of Resident #21's (who resides in the secure unit) medical record stated Resident #21 is an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated Resident #21 needed supervision and one person physical assist with transfer, dressing, and eating. Resident #21 needed extensive assistance with 1 person for bathing. Resident #21 was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #21's BIMS score was 5 (severe impairment). Review of Resident #21's care plan revealed Resident #21 was a high risk for falls. Record Review of Resident #22's (who resides in the secure unit) medical record stated Resident #22 is [AGE] years of age and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed that Resident #22 needs supervision with one person for transfer, supervision and set-up help for dressing, and eating. Resident #22 needs extensive assistance with 1 person for bathing. Resident #22 is occasionally incontinent of bowel and bladder. Resident #22's BIMS score is 6 (severely impaired). Review of Resident #22's care plan revealed Resident #22 was a high risk for falls. Record review of Resident #23's (who resides in the secure unit) medical record stated Resident #23 is an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the annual MDS assessment dated [DATE] showed that Resident #23 needed supervision and set up help for transfer, and eating. Resident #23 needed limited assistance with one person for eating, and dressing. Resident #23 needed physical help with one person for bathing. Resident #23's BIMS score was 2 (severely impaired). Review of the fall risk assessment for Resident #23 on 3-19-15 showed a score of 10 (high risk for falls). Review of Event Nurses Notes dated 12/15/14 revealed an un-witnessed fall. Obstacles noted: blanket/walker. Facility interventions initiated after the fall: monitor regularly and take to the bathroom every 2 hours. Resident #23's care plan dated 12/15/14 showed she is a high risk for falls. Interventions listed for Resident #23 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #23's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; anticipate resident needs 12/15/14. Review of Resident #23's fall care plan revealed the facility did not ensure Resident #23's room was free from clutter as attested in the event nurses note on 12/15/14 that listed a blanket and walker as obstacles. Record review of Resident #24 (who resides in the secure unit) revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the quarterly MDS dated [DATE] showed that Resident #24 needed extensive assistance with two people for transfer, and dressing. Resident #24 needed extensive assistance with one person for eating and bathing. Resident #24's BIMS score was 00. Resident #24 was frequently incontinent of bowel and bladder. Review of the fall risk assessment for Resident #24 on 1-16-15 showed a score of 14 (high risk for falls). Review of an Event Nurses Note dated 1/16/15 revealed an un-witnessed fall. Obstacles involved; roommates wheelchair. Facility interventions initiated after the fall;low bed, house shoes and non-skid socks. Resident #24's care plan dated 1/16/15 showed Resident #24 is a high risk for falls. Interventions listed for Resident #24 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #24's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; other - remove obstacles in room [ROOM NUMBER]/16/15. Review of Resident #24's fall care plan revealed obstacles were not removed from Resident #24's room until after a fall occurred. The roommates wheelchiar was left in the way and this is what Resident #24 fell on . Record Review of Resident #25 (who resides in the secure unit) revealed that Resident #25 is a [AGE] year old with the following Diagnoses: [REDACTED]. Review of the fall risk assessment for Resident #25 on 1-16-15 showed a score of 20 (high risk for falls). Review of an Event Nurses Note dated 12/14/14 revealed a witnessed fall. No facility initiated interventions after the event were checked. Review of a Nurses Note - Fall (no date on form) for Resident #25 revealed approaches taken by the facility; Body alarm for bed and chair, low bed and wheelchair. Resident #25's care plan dated 12-14-14 showed Resident #25 is a high risk for falls. Interventions listed for Resident #25 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #25's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #25's fall care plan revealed the facility did not perform a fall risk assessment after the 12/14/14 fall. Review of the quarterly MDS dated [DATE] revealed that Resident #25 needed extensive assistance with one person for transfer, and eating. Resident #25 needed extensive assistance with 2 people for dressing. Resident #25 was totally dependent with one person for bathing. Resident #25 is always incontinent of bladder and frequently incontinent of bowel. Resident #25's BIMS score is 3 (severely impaired). Record review of Resident #27's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated that Resident #27 requires extensive assistance with one person for transfer, dressing, eating and total dependence with two people for bathing. Resident #27 is always incontinent of urine and frequently incontinent of bowel. Resident #2's BIMS score is 3 (severely impaired). Review of Resident #27's Fall Risk assessment dated [DATE] revealed a score of 10 (high risk for falls). Review of an Event Nurses Note dated 12/4/14 revealed a witnessed fall. There were no interventions initiated by the facility after the fall. Resident #27's care plan dated 12/4/14 showed Resident #27 is a high risk for falls. Interventions listed for Resident #27 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #27's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #27's fall care plan revealed the facility did not perform a fall risk assessment after the 12/4/14 fall. There were 2 additional fall risk assessments done on 1/19/15 and 3/19/15 that scored Resident #27 a 9 (low risk for falls). Review of the above information revealed; 7 residents in the secure unit were at risk for falls, 3 residents required two people for transfer. There were 9 residents that are incontinent of bowel and bladder and require assistance for toileting. All 10 residents of the secure unit had a BIMS score of 6 or less which is significant impairment. During an interview with the DON on 3-25-15 at 4:00 p.m. she was asked about the staffing in the secure unit in regards to falls, she stated there was one CNA on the unit both day and night. We have a float that usually goes back every hour to check in the secure unit. The CNA on the secure unit will call for help if needed. The DON stated she felt like it was adequately staffed. During an additional interview with the DON on 3-26-15 at 2:35 p.m. the DON was asked about CNA K leaving Resident #1 unattended, and the DON stated that CNA K should not have left Resident #1 unattended. "Our procedure is to call for another staff to come and cover when we go to the bathroom." Review of the staffing sheet for the secure unit showed for March 1 through March 25 there were 14 days with a CNA assigned to float and 7 days where there was not a float assigned at all. On 5 days there was only partial coverage, there was not a float assigned for the entire shift. On the afternoon of 3-19-15 there was not a float assigned. During an interview in the secure unit with CNA F on 3-25-14 at 3:10 p.m. she stated she works the 2:00 p.m. to 10:00 p.m. shift. "It is always just myself working with all the residents here. If anyone needs assistance, it leaves everyone else by themselves." During an interview with LVN E on 3-25-15 at 7:00 p.m. she was asked how many aides are in the secure unit, LVN E stated that only one aide works in the secure unit. LVN E said "I stay at the main nurse's station and I pass meds for the secured unit and Hall #6." During an interview with HA on 3-25-15 at 6:50 p.m. when was asked if he worked in the secure unit HA stated "I pass ice; I don't provide any personal care." During an interview with CNA L on 3-25-15 at 6:55 p.m. CNA L stated, "I work the 2:00 p.m. to 10:00 p.m. shift in the secure unit. We have a float and they help if needed." During an interview with the DON on 3-25-14 at 5:00 she was asked for the names and numbers of the CNA and LVN that were working in the secure unit the night Resident #19 came back from the hospital. The DON gave surveyor two LVN's names, LVN A and LVN B. The DON stated she was not sure what nurse was working in the secure unit that evening. A call was placed at 5:18 p.m. to LVN A which was not returned. A call to LVN B at 5:17 p.m. was not returned. The DON was asked for the name of the aide working in the secure unit on 3-19-15 and the DON stated it was CNA I, but could only give surveyor the first name. Surveyor looked up the last name and called CNA I at 5:15 p.m. there was no answer. Review of the facility provided policy and procedure for Preventive Strategies to Reduce Fall Risks dated 5-20-2011 stated: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. 12. Nursing Care: Maintain regular toileting schedules, Place confused Residents close to the nurse's station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. 13. Use bed/chair alarms systems to monitor unsafe activity as needed. Review of the policy and Procedure provided by the facility for Secure Care Environment Staffing Requirements stated: The Secure Care Environment will provide therapeutic staffing to meet the distinct needs of residents with wandering and dementia related disorders. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of the residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the Secure Care Environment. Policy: 1. The Secure Care environment will employ licensed nurses and certified nurse's aides for direct patient care. The Secure Environment will be staffed to meet the needs of each resident. The facility Administrator was notified on 3/25/15 at 5:50 p.m. that an IJ situation had been identified due to the above failures. The facility's Plan of Removal was provided by the Administrator on 3/26/15 at 10:50 am. The Plan of Removal was accepted at 11:11 a.m. on 3/26/15. The facility took the following actions to remove the immediacy of the IJ: 1. Two staff members will be on the secure unit for each of the three shifts; with 2 staff members on the secure unit at all times - one staff member can also be sent to notify the charge nurse if extra intervention is needed. 2. The staff will be immediately in-serviced on how to reach the nurse when needed i.e. phone call to the desk, intercom to page a nurse to the secure unit, and walkie-talkies for communication with the nurse assigned to the secured unit. 3. All staff that work on the secure unit will be in-serviced before they start their next shift on: a. falls and fall prevention b. how to care for a resident with a hip injury i.e. turning and transfers c. verbal and non-verbal pain indications and pain assessments 4. All residents in the secured unit and the rest of the facility will be assessed for pain immediately on 3/26/15, and pain management will be initiated if needed per physician orders. All residents will have a pain assessment performed upon admission, quarterly, with a significant change, and upon resident complaint of pain. 5. All residents will have the current Fall Risk Assessment reviews and updated as needed on 3/26/15, and care plans will be updated. 6. Residents with multiple falls will have new interventions considered and implemented of appropriate as the care plan is updated as needed. (See attached Event Nurses Note). 7. The DON will review all incidents to make sure appropriate interventions are updated and in place, as well as care plans updated as needed. 8. A review of the last 30 days of event notes of falls will be completed to check that the appropriate interventions are in place. 9. The plan will be reviewed by the QAPI committee weekly for 4 weeks, and then monthly for 90 days. Observations on 3/26/1

Based on observation, interview and record review, the Administrator and the Director of Nurses failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental and psychosocial well-being for 6 of 10 residents (Residents #1, #19, #23, #24, #25, #27) reviewed for neglect, in that: 1. The ADM failed to implement the facility's policy for Preventive Strategies to Reduce Fall Risks. 6 Residents in the secured unit, at high risk for falls, had a total of 19 falls in a 3 month time frame. 2. The ADM failed to implement the facility's policies and procedures for the prevention of neglect. Appropriate staffing for adequate supervision was not provided when Resident #1 had 12 falls (10 un-witnessed) in the secure unit of the facility over a 3 month time frame. The last fall resulted in a [MEDICAL CONDITION] that had to be surgically repaired. 3. The DON failed to adequately assign staff in the secured unit to ensure the needs of the Residents were met. 4. The facility to provide sufficient staff in the secured unit. Care plans and MDS requirements indicated that two or more staff were required to provide care for residents in the secured unit. There was only one CNA scheduled to work in the secure unit on both day and night shifts. The LVN assigned to the secure unit only comes when she is called for. 5. The DON failed to ensure that Resident #1 received appropriate pain intervention on the night she returned to the facility following surgical [MEDICAL CONDITION] hospitalization when no pain medication was administered for 12 hours. There was only one CNA in the secured unit who stated that she could not leave to go get the nurse. 6. The ADM and DON failed to train the facility staff in the care and services of a resident that has had a recent [MEDICAL CONDITION] repair when an observation of incontinent care revealed Resident #1's left foot (the side of the [MEDICAL CONDITION]) was improperly crossed over her right foot; and no abduction pillow was placed between her legs before attempting to roll her to her side. Resident #1 screamed in pain when the aides tried to roll her to her side. There was no training for care and services for a resident with a recent [MEDICAL CONDITION] performed for the staff providing care for Resident #1. These failures resulted in identification of an IJ (Immediate Jeopardy) on 3/25/15. While the immediacy of the IJ was removed on 3/26/15, the facility remained out of compliance at a severity level of harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. These failures by the ADM and DON of not implementing their policies, providing adequate staff and supervision could affect all 10 Residents in the secure unit by placing them at risk for falls with major injury. Findings include: Record review of Resident #1's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review indicates that Resident #1 had her first fall, which was unwitnessed and the resident was found next to the bed, on the night of admission on 12/9/14. The incident report states that the facility will place a bed pressure alarm. Review of incident reports shows a second unwitnessed fall, where the resident was found next to the wheelchair, for Resident #1 on 12/15/14. The incident report indicates that frequent monitoring will be initiated after this fall, and no care plan was initiated. The next incident report indicating a witnessed fall (fall #3) was on 12/23/14. Interventions listed on the incident report state chair alarm and frequent monitoring. Once again no care plan was initiated. *+Review of the facility's fall care plan initiated on 12/28/14, after Resident #1 experienced the 4th fall (witnessed) stated the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs The incident report for fall #4 on 12/28/14 states that the interventions initiated after the fall will include bed and chair alarms and a low bed. It also says they will continue frequent monitoring which is not included on the interventions on the fall care plan. Review of the incident report for the 5th fall, which was unwitnessed and the resident was found next to her wheelchair, on 12/29/14 includes interventions of body alarm, pressure alarms, and low bed. It also states, "Instructed CNA to do hourly rounds and make sure that the bed is in low position and the alarms are on if in bed or chair. * No revisions or additions were made to the care plan at this time. On 12/30/14 there was no incident report for a fall; however, an intervention of adding a drop seat to the wheelchair was added to the fall care plan for Resident #1. Review of the incident report for the 6th fall, which was unwitnessed and the resident fell from her wheelchair, on 1/1/15 states that the chair alarm will be re-initiated. The Fall Care Plan was updated at this time. It states, "Educate staff to stay with resident while in wheelchair." Review of the incident report for the 7th fall on 1/18/15, which was unwitnessed has no new interventions listed on the report; however, the care plan was updated to include every 2 hour monitoring. Review of the incident report for the 8th fall on 2/2/15, which was unwitnessed states that the aid did not hear the alarm go off and the the resident was found on the floor close to the bathroom doorway. The report includes the new intervention: "Educate all staff of importance of alarms." **There is a new care plan for falls for Resident #1 started on 2/2/15 that lists the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Drop seat in wheelchair Every two hour toileting program PT (physical therapy) referral Please note the interventions are no longer in place to: 1. Monitor the resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair Review of the incident report for the 9th fall on 2/6/15, which was unwitnessed and no alarm was heard by the CNA on duty where the resident was found in the corner next to the closet, states to add anti-slip socks, which was not added to the resident's fall care plan. Resident #1 had a laceration on her back from this fall. Review of the incident for the 10th fall on 2/27/15 at 12:00 p.m., which was unwitnessed and the resident was found on the floor, includes the intervention of collect urine sample for confusion, which was added to the care plan. Review of the incident report for the 11th fall on 2/27/15 at 2:30 a.m., which was unwitnessed and the resident was found on the floor next to her bed, has the following interventions listed: "ensured all alarms working monitor frequently." Frequent monitoring is not on the current Fall Care Plan for Resident #1. Review of the incident report for the 12th fall on 3/15/15, which was unwitnessed and the resident was found in the floor between the hallway and the dining room, has no new interventions. The resident was transported by ambulance to the emergency room and had surgical intervention for a [MEDICAL CONDITION]. *** A third Fall Care Plan was put into place at this time and the only interventions listed on this third care plan are as follows: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Encourage the resident to use appropriate footwear Encourage use of call light Bed Alarm Chair Alarm Toileting Program Low Bed Floor Mat Please note the interventions are no longer in place to: 1. Monitor the resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair 4. Drop seat in wheelchair 5. Scoop Mattress 6. Physical Therapy referral Record review of the Quarterly MDS dated [DATE] showed that Resident #1 had a BIMS score of 2 (severely impaired) and required extensive assistance with two people for transfer, bathing, and dressing. Resident #1 needed extensive assistance from one person to assist for eating and hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of bladder. Record review of the fall risk assessment for Resident #1 on 3-15-15 showed a score of 20 (high risk for falls). Review of the facility investigation report stated on 3-15-15 at 4:30 p.m. Resident #1 sustained a fall in the secure unit of the facility, 911 was called and Resident #1 was transferred to the emergency room , where an x-ray revealed she had a fractured left hip. Resident #1 then was sent to the hospital for surgical hip repair. The facility investigation report completed by the ADM and dated 3-16-15 stated, "All residents of the secure unit were in the dining room waiting for supper to be served. Resident #1 was the second to last resident that was brought in the dining room and was in her wheelchair. The CNA was getting the last resident up with the help of another aide. The other aide had just left and the CNA on the unit was completing her tasks with the last resident when she heard Resident #1's chair alarm going off and immediately went to investigate, but the resident was already on the floor." The investigation written report statement provided by CNA K (the CNA in the secure unit at the time of the fall) dated 3-15-15 stated that Resident #1 was sitting in the dining room in a chair with her alarm under her and activated. I went into the bathroom and when I heard her alarm go off, I rushed out of the bathroom and found Resident #1 on the ground in the doorway of the dining room complaining that her hip was hurting. I pulled an emergency light and waited with her until help arrived. During an interview with the ADM on 3-24-15 at 4:30 p.m. when asked about the Resident #1's fall she stated, "Resident #1 was on the secure unit and she was in the dining room in a wheel chair with the alarm on. She had a [MEDICAL CONDITION]; she is constantly trying to get up. The aide was helping Resident # 19 into her chair and the floater had left, I don't know the aides name that remained on the unit. She heard the alarm, went over to the dining room and Resident #1 was already on the floor. She obviously had a fracture, she was left on the floor and 911 was called. She went to the hospital with a [MEDICAL CONDITION]." In a follow-up interview with the ADM on 3/26/15 at 1:30 p.m. she stated Resident #1 should have had one on one care from her family. When she was asked about CNA K leaving the residents unsupervised to go to the restroom her response was, "Everyone has to go to the bathroom. We leave residents unattended all of the time." During an interview with the DON on 3-25-15 at 4:00 p.m. she was asked about the staffing in the secure unit in regards to falls, she stated there was one CNA on the unit both day and night. We have a float that usually goes back every hour to check in the secure unit. The CNA on the secure unit will call for help if needed. The DON stated she felt like it was adequately staffed. During an additional interview with the DON on 3-26-15 at 2:35 p.m., the DON stated the incidents that lead up to the events with Resident #1 (repetitive falls, [MEDICAL CONDITION], lack of pain intervention, and improper care of a post-surgical [MEDICAL CONDITION] patient) were due to education that was missing and also re-education of these issues. When asked if she thought CNA K should have called for assistance when she left Resident #1 unattended to go to the restroom she stated, "CNA K should not have left the residents unattended. Our procedure is to call for another staff to come and cover when we go to the bathroom." An interview with CNA K on 3-25-15 at 5:15 p.m. revealed that CNA K was working on the secure unit when Resident #1 fell . CNA K stated, "I was working as a CNA on the secure unit. I was the only one there, Resident #1 wanted to sit in a regular chair. I put the chair alarm on the regular chair and Resident #1 sat down, then I went to the bathroom. I heard the alarm and when I came out Resident #1 was on the floor." CNA K stated she stays back in the secure unit, and the only time she has another person in the secure unit is if she calls for help. CNA K was asked if she felt she should have called for help when she needed to go to the restroom and she stated, "Resident #1 seemed fine, but maybe I should have called for help." CNA K stated there is always only one aide in the secure unit unless they need help. Observation on 3-24-15 at 12:00 p.m. revealed Resident #1 sitting in a geri chair in the dining room of the secure unit. There was no chair alarm or personal alarm on Resident #1's person or chair. Record review of the additional incident and accident reports for the secure unit revealed that there were 7 additional falls involving five different residents; for a total of 19 falls over a four month period in the secure unit from 11-16-15 through 3-15-15. Resident #19: Record review of Resident #19 (who resides in the secure unit) medical record revealed an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #19 needed extensive assistance and 2 people for transfers, and dressing. For bathing Resident #19 was totally dependent with one person. Resident #19 is frequently incontinent of bowel and bladder. Resident #19's BIMS score was 3 (severely impaired). Review of the fall risk assessment for Resident #19 on 3-25-15 showed a score of 19 (high risk for falls). Review of Event Nurses Notes (Incident Report) for Resident #19 dated 1/20/15 revealed a witnessed fall. The facility intervention initiated after the fall: vitals and shoes/slip socks. Review of Event Nurses Notes for Resident #19 dated 1/21/15 revealed an un-witnessed fall. The facility intervention initiated after the fall: Pressure alarm (Bed), and encouraged resident to use call light for assist. Review of Event Nurses Notes for Resident #19 dated 2/27/15 revealed a witnessed fall. The facility intervention initiated after the fall: other box checked but nothing was written (left blank). Resident #19's care plan showed she is a high risk for falls. Interventions listed for Resident #19 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #19's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; Encourage use of call light and other: staff to anticipate resident needs 2/27/15. Review of Resident #19's Falls Care Plan revealed the facility did not do a fall risk assessment after each fall on 1/20/15 and 1/21/15. Resident #23: Record review of Resident #23's (who resides in the secure unit) medical record stated Resident #23 is an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the annual MDS assessment dated [DATE] showed that Resident #23 needed supervision and set up help for transfer, and eating. Resident #23 needed limited assistance with one person for eating, and dressing. Resident #23 needed physical help with one person for bathing. Resident #23's BIMS score was 2 (severely impaired). Review of the fall risk assessment for Resident #23 on 3-19-15 showed a score of 10 (high risk for falls). Review of Event Nurses Notes dated 12/15/14 revealed an un-witnessed fall. Obstacles noted: blanket/walker. Facility interventions initiated after the fall: monitor regularly and take to the bathroom every 2 hours. Resident #23's care plan showed she is a high risk for falls. Interventions listed for Resident #23 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #23's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; anticipate resident needs 12/15/14. Review of Resident #23's fall care plan revealed the facility did not ensure Resident #23's room was free from clutter as attested in the event nurses note on 12/15/14 that listed a blanket and walker as obstacles. Resident #24: Record review of Resident #24 (who resides in the secure unit) revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the quarterly MDS dated [DATE] showed that Resident #24 needed extensive assistance with two people for transfer, and dressing. Resident #24 needed extensive assistance with one person for eating and bathing. Resident #24's BIMS score was 00. Resident #24 was frequently incontinent of bowel and bladder. Review of the fall risk assessment for Resident #24 on 1-16-15 showed a score of 14 (high risk for falls). Review of an Event Nurses Note dated 1/16/15 revealed an un-witnessed fall. Obstacles involved; roommates wheelchair. Facility interventions initiated after the fall;low bed, house shoes and non-skid socks. Resident #24's care plan showed Resident #24 is a high risk for falls. Interventions listed for Resident #24 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #24's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; other - remove obstacles in room [ROOM NUMBER]/16/15. Review of Resident #24's fall care plan revealed obstacles were not removed from Resident #24's room until after a fall occurred. Resident #25: Record Review of Resident #25 (who resides in the secure unit) revealed that Resident #25 is a [AGE] year old with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed that Resident #25 needed extensive assistance with one person for transfer, and eating. Resident #25 needed extensive assistance with 2 people for dressing. Resident #25 was totally dependent with one person for bathing. Resident #25 is always incontinent of bladder and frequently incontinent of bowel. Resident #25's BIMS score is 3 (severely impaired). Review of the fall risk assessment for Resident #25 on 1-16-15 showed a score of 20 (high risk for falls). Review of an Event Nurses Note dated 12/14/14 revealed a witnessed fall. No facility initiated interventions after the event were checked. Review of a Nurses Note - Fall (no date on form) for Resident #25 revealed approaches taken by the facility; Body alarm for bed and chair, low bed and wheelchair. Resident #25's care plan showed Resident #25 is a high risk for falls. Interventions listed for Resident #25 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #25's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #25's fall care plan revealed the facility did not perform a fall risk assessment after the 12/14/14 fall. Resident #27: Record review of Resident #27's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated that Resident #27 requires extensive assistance with one person for transfer, dressing, eating and total dependence with two people for bathing. Resident #27 is always incontinent of urine and frequently incontinent of bowel. Resident #2's BIMS score is 3 (severely impaired). Review of Resident #27's Fall Risk assessment dated [DATE] revealed a score of 10 (high risk for falls). Review of an Event Nurses Note dated 12/4/14 revealed a witnessed fall. There were no interventions initiated by the facility after the fall. Resident #27's care plan showed Resident #27 is a high risk for falls. Interventions listed for Resident #27 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #27's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #27's fall care plan revealed the facility did not perform a fall risk assessment after the 12/4/14 fall. There were 2 additional fall risk assessments done on 1/19/15 and 3/19/15 that scored Resident #27 a 9 (low risk for falls). Review of the staffing sheet for the secure unit showed for March 1 through March 25 there were 7 days where there was not a float assigned at all, and on 5 additional days there was a CNA assigned to only a partial shift coverage as a float. During a confidential interview with interviewee on 3-25-15 at 11:10 a.m. interviewee stated that Resident #1 came back from the hospital after her surgical hip repair on 3-19-15. Resident #1 was not given any pain medication throughout the night shift on 3-19-15. Interviewee stated that Resident #1 was moaning and yelling during the night, and when she asked about pain medication interviewee was told that the nurse was out in the other part of the facility and interviewee would have to go get the nurse for pain medication. The CNA told her she couldn't leave the unit; no call was made to the nurse. Interviewee stated the LVN's assigned to the secure unit do not stay in the unit and are not aware if someone needs pain. Interviewee stated the nurse did not come back to the secure unit during the evening/night. Interviewee stated Resident #1 was getting pain medication every 4 hours while in the hospital. Interviewee stated there is only one aide on the secure unit at any time, and that is not enough for the type of people they are caring for and how many people they are caring for. Review of the facility Individual Control Drug Record showed the order for pain medication for Resident #1 was [MEDICATION NAME] 50mg every 4 hours as needed. Resident #1 arrived back at the facility following hip repair on 3-19-15 at 11:30 a.m. Review of the narcotic log for [MEDICATION NAME] showed it was given to Resident #1 on 3-19-15 at 8:00 p.m. and not again until 8:24 a.m. on 3-20-15. There was no pain assessment completed upon Resident #1's return to the facility on [DATE]. The most current pain assessment was completed on 3-25-15, 7 days after coming back to the facility which was completed after surveyor intervention. During an interview in the secure unit with CNA F on 3-25-14 at 3:10 p.m. she stated she works the 2:00 p.m. to 10:00 p.m. shift. "It is always just myself working with all the residents here. If anyone needs assistance, it leaves everyone else (the rest of the residents in the secured unit) by themselves." During an interview with LVN E on 3-25-15 at 7:00 p.m. she was asked how many aides are in the secure unit, LVN E stated that only one aide works in the secure unit. LVN E said "I stay at the main nurse's station and I pass meds for the secured unit and Hall #6." During an interview with HA on 3-25-15 at 6:50 p.m. when was asked if he worked in the secure unit HA stated, "I pass ice; I don't provide any personal care." During an interview with CNA L on 3-25-15 at 6:55 p.m. CNA L stated, "I work the 2:00 p.m. to 10:00 p.m. shift in the secure unit. We have a float and they help if needed." During observation of incontinent care on 3-25-15 at 3:15 p.m. in the secure unit Resident #1 was being transferred from her geri-chair to her bed to provide care. CNA's J and F were in attendance. Resident #1 was transferred by gait belt onto the bed; Resident #1's pants were soaked with urine when aides got her out of her geri-chair. When the aides began to provide incontinent care, they crossed Resident #1's left leg over the right leg at the ankle (Resident #1 is just 5 days post-op for a [MEDICAL CONDITION]) to roll her to the side. Resident #1 screamed out in pain. Both CNA J and F were by asked by surveyor to stop moving Resident #1. The CNA's were asked if they knew how to move a fresh hip replacement and they stated they had not been trained. The surveyor went out into the dining area of the secure unit and LVN C had come into the room and was asked how to move a fresh hip replacement she stated, "Obviously not like this," pointing to Resident Carter's crossed ankles. LVN C said they would get Resident #1 some pain medication and then try to provide incontinent care again. During an interview with the DON on 3-25-14 at 4:00 p.m. she was asked about the lack of education in regard to transferring and moving a resident with a recent surgical repair of the hip. The DON stated there was no care plan specifically for Resident #1 on how to care for a resident with a new hip repair. The DON stated she will educate the staff on transfer and rolling Resident #1 and how to do this. The DON was asked about Resident #1's pants being soaking wet, the DON stated she wasn't wet at 11:00 and she was checked at 1:00 p.m. and wasn't wet. During an interview with PT 3-26-15 at 1:30 a.m. she was asked how she trained staff to care for Resident #1 due to the fact she was in extreme pain from the improper technique used while moving her. PT stated, "I am teaching them when they are lying down, to roll to the unaffected side, place a pillow between the legs, with the legs not bent past 90 degrees." Observations of the secured unit on 3/24/15 and 3/25/15 show there is not an LVN in the secure unit unless they are called. Interviews show the CNA's were not trained in recognizing verbal and non-verbal pain. Review of the facility provided policy and procedure for Preventive Strategies to Reduce Fall Risks dated 5-20-2011 stated: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. 12. Nursing Care: Maintain regular toileting schedules, Place confused Residents close to the nurse's station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. 13. Use bed/chair alarms systems to monitor unsafe activity as needed. Review of the policy and Procedure provided by the facility for Secure Care Environment Staffing Requirements stated: The Secure Care Environment will provide therapeutic staffing to meet the distinct needs of residents with wandering and dementia related disorders. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of the residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the Secure Care Environment. Policy: 1. The Secure Care environment will employ licensed nurses and certified nurse's aides for direct patient care. The Secure Environment will be staffed to meet the needs of each resident. The facility provided policy and procedure for Pain Management, Assessment Scale stated: Policy: Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications and comfort measures, and all available resources for the facility. Procedure: 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. The nurse may use the Pain Assessment Tool to complete the resident's complaint of pain. The completed tool will be placed in the resident's clinical record. 2. Administer pain medications as prescribed. Monitor and record medications effectiveness and side effects. 7. Help resident into a comfortable position and use pillows to splint or support painful areas as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. The facility Administrator was notified on 3/25/15 at 5:50 p.m. that an IJ situation had been identified due to the above failures. The facility's Plan of Removal was provided by the Administrator on 3/26/15 at 10:50 am. The Plan of Removal was accepted at 11:11 a.m. on 3/26/15. The facility took the following actions to remove the immediacy of the IJ: 1. Two staff members will be on the secure unit for each of the three shifts; with 2 staff members on the secure unit at all times - one staff member can also be sent to notify the charge nurse if extra intervention is needed. 2. The staff will be immediately in-serviced on how to reach the nurse when needed i.e. phone call to the desk, intercom to page a nurse to the secure unit, and walkie-talkies for communication with the nurse assigned to the secured unit. 3. All staff that work on the secure unit will be in-serviced before they start their next shift on: a. falls and fall prevention b. how to care for a resident with a hip injury i.e. turning and transfers c. verbal and non-verbal pain indications and pain assessments 4. All residents in the secured unit and the rest of the facility will be assessed for pain immediately on 3/26/15, and pain management will be initiated if needed per physician orders. All residents will have a pain assessment performed upon admission, quarterly, with a significant change, and upon resident complaint of pain. 5. All residents will have the current Fall Risk Assessment reviews and updated as needed on 3/26/15, and care plans will be updated. 6. Residents with multiple falls will have new interventions c

Based on observation, interview and record review the facility failed to implement their written policies and procedures that prohibit neglect for 6 of 10 residents reviewed for neglect, whom reside in the secure unit, (Residents #1, #19, #23, #24, #25, and #27) when; 1. The facility failed to supervise Resident #1 when she had 12 falls (10 un-witnessed) in the secure unit of the facility over a 3 month time frame. The last fall occurred while she was not being supervised by any facility staff and resulted in a [MEDICAL CONDITION] that had to be surgically repaired. The one staff member on duty the day that Resident #1 experienced a fall with fracture (CNAK) had gone to the bathroom and did not call for any assistance from other staff to supervise the residents while she was in the restroom which is the procedure of the facility according to the DON. 2.. The facility failed to change staffing patterns in the secured unit when there were an additional 7 falls (3 un-witnessed) by 5 different residents (Residents #19, #23, #24, #25, and #27) in the secure unit of the facility during this three month time frame. The facility failed to staff the secure unit with sufficient staff to meet the requirements outlined in the MDS and care plans for the 10 residents residing in the secure unit, that required more supervision related to the residents fall risk, behaviors, and increased need for assistance with activities of daily living. These failures resulted in identification of an IJ (Immediate Jeopardy) on 3/25/15. While the immediacy of the IJ was removed on 3/26/15, the facility remained out of compliance at a severity level of harm and a scope of a pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The facility's failure to adequately supervise the 10 residents in the secure unit to prevent falls affected Resident #1 when she had a fall with fracture that required surgical intervention. The failure also affected the 6 residents that had falls, and could affect the remaining 4 residents that reside in the secure unit by placing them at risk for falls with major injury. Findings include: Review of the facility's policy and procedure for Abuse/Neglect dated 1-8-2003 stated: 6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Identification: 6. The Task G Coordinator and/or administrator will conduct a thorough investigation of the incident. F. Protection: The QA committee will analyze Abuse and Neglect policies/procedures following an investigation or at least quarterly to determine if changes to the policy and procedure need to be made. Review of the facility provided policy and procedure for Preventive Strategies to Reduce Fall Risks dated 5-20-2011 stated: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. 12. Nursing Care: Maintain regular toileting schedules, Place confused Residents close to the nurse's station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. 13. Use bed/chair alarms systems to monitor unsafe activity as needed. Review of the policy and Procedure provided by the facility for Secure Care Environment Staffing Requirements stated: The Secure Care Environment will provide therapeutic staffing to meet the distinct needs of residents with wandering and dementia related disorders. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of the residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the Secure Care Environment. Policy: 1. The Secure Care environment will employ licensed nurses and certified nurse's aides for direct patient care. The Secure Environment will be staffed to meet the needs of each resident. Resident #1: Record review of Resident #1's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #1's clinical record revealed that there was no care plan in place prior to the first fall. A fall risk assessment was performed on 12/9/14 at the time of the first fall and indicated that Resident #1 was at a low risk for falls. Record review indicates that Resident #1 had her first fall, which was unwitnessed and the resident was found next to the bed, on the night of admission on 12/9/14. The incident report states that the facility will place a bed pressure alarm. Review of incident reports shows a second unwitnessed fall, where the resident was found next to the wheelchair, for Resident #1 on 12/15/14. The incident report indicates that frequent monitoring will be initiated after this fall, and no care plan was initiated. A fall risk assessment was performed on 12/15/14 at the time of the fall and indicated that Resident #1 was at a low risk for falls. The next incident report indicating a witnessed fall (fall #3) was on 12/23/14. Interventions listed on the incident report state chair alarm and frequent monitoring. Once again no care plan was initiated. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. The incident report for fall #4 on 12/28/14 stated that the interventions initiated after the fall will include bed and chair alarms and a low bed. It also stated they will continue frequent monitoring which is not included on the interventions on the fall care plan. A fall risk assessment was performed on 12/23/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the facility's fall care plan initiated on 12/28/14, after Resident #1 experienced the 4th fall (witnessed) stated the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Review of the incident report for the 5th fall, which was unwitnessed and the resident was found next to her wheelchair, on 12/29/14 includes interventions of body alarm, pressure alarms, and low bed. It also stated, "Instructed CNA to do hourly rounds and make sure that the bed is in low position and the alarms are on if in bed or chair. The care plan was not updated to include the intervention of hourly rounds. On 12/30/14 there was no incident report for a fall; however, an intervention of adding a drop seat to the wheelchair was added to the fall care plan for Resident #1. A fall risk assessment was performed on 12/30/14 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 6th fall, which was unwitnessed and the resident fell from her wheelchair, on 1/1/15 stated that the chair alarm will be re-initiated. The Fall Care Plan dated 12/30/14 was updated at this time to include, "Educate staff to stay with resident while in wheelchair." A fall risk assessment was performed on 1/1/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 7th fall on 1/18/15, which was unwitnessed has no new interventions listed on the report; however, the care plan was updated to include every 2 hour monitoring. A fall risk assessment was performed on 1/18/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 8th fall on 2/2/15, which was unwitnessed states that the aide did not hear the alarm go off and the the resident was found on the floor close to the bathroom doorway. The report includes the new intervention: "Educate all staff of importance of alarms." A fall risk assessment was performed on 2/2/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. There was a new care plan for falls for Resident #1 started on 2/2/15 that lists the following interventions: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Bed Alarm Chair Alarm Low bed Floor mat Educate staff to anticipate resident needs Drop seat in wheelchair Every two hour toileting program PT (physical therapy) referral Please note the interventions are no longer in place to: 1. Instructed the CNA to do hourly rounds and make sure the bed is in low position and the alarms are on if in bed or chair. 2. Monitor resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair Review of the incident report for the 9th fall on 2/6/15, which was unwitnessed and no alarm was heard by the CNA on duty where the resident was found in the corner next to the closet, states to add anti-slip socks, which was not added to the resident's fall care plan. Resident #1 had a laceration on her back from this fall. A fall risk assessment was performed on 2/6/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident for the 10th fall on 2/27/15 at 12:00 p.m., which was unwitnessed and the resident was found on the floor, includes the intervention of collect urine sample for confusion, which was added to the care plan. A fall risk assessment was performed on 2/27/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. Review of the incident report for the 11th fall on 2/27/15 at 2:30 a.m., which was unwitnessed and the resident was found on the floor next to her bed, has the following interventions listed: "ensured all alarms working monitor frequently." Frequent monitoring is not on the current Fall Care Plan for Resident #1. Review of the incident report for the 12th fall on 3/15/15, which was unwitnessed and the resident was found in the floor between the hallway and the dining room, has no new interventions. The resident was transported by ambulance to the emergency room and had surgical intervention for a [MEDICAL CONDITION]. A fall risk assessment was performed on 3/15/15 at the time of the fall and indicated that Resident #1 was at a high risk for falls. A third Fall Care Plan was put into place at this time and the only interventions listed on this third care plan are as follows: Keep the resident's room free of clutter Refer to therapy as needed Ensure resident's living area has proper lighting Keep the resident's call light in reach while they are in their room Fall risk assessment on admit, quarterly, and after a fall Notify the physician and family of any changes Encourage the resident to use appropriate footwear Encourage use of call light Bed Alarm Chair Alarm Toileting Program Low Bed Floor Mat Please note the interventions are no longer in place to: 1. Monitor the resident every two hours 2. Educate staff to anticipate resident's needs 3. Educate staff to stay with resident while in wheelchair 4. Drop seat in wheelchair 5. Scoop Mattress 6. Physical Therapy referral Record review of the Quarterly MDS dated [DATE] showed that Resident #1 had a BIMS score of 2 (severely impaired) and required extensive assistance with two people for transfer, bathing, and dressing. Resident #1 needed extensive assistance from one person to assist for eating and hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of bladder. Record review of the fall risk assessment for Resident #1 on 3-15-15 showed a score of 20 (high risk for falls). Review of the facility investigation report stated on 3-15-15 at 4:30 p.m. Resident #1 sustained a fall in the secure unit of the facility, 911 was called and Resident #1 was transferred to the emergency room , where an x-ray revealed she had a fractured left hip. Resident #1 then was sent to the hospital for surgical hip repair. The facility investigation report completed by the ADM and dated 3-16-15 stated that " All residents of the secure unit were in the dining room waiting for supper to be served. Resident #1 was the second to last resident that was brought in the dining room. CNA was getting the last resident up with the help of another aide. The other aide had just left and the CNA on the unit was completing her tasks with the last resident when she heard Resident #1's chair alarm going off and immediately went to investigate, but the resident was already on the floor." The investigation written report statement provided by CNA K (the CNA in the secure unit at the time of the fall) dated 3-15-15 stated that "Resident #1 was sitting in the dining room in a chair with her alarm under her and activated. I went into the bathroom and when I heard her alarm go off, I rushed out of the bathroom and found Resident #1 on the ground in the doorway of the dining room complaining that her hip was hurting. I pulled an emergency light and waited with her until help arrived." During an interview with the ADM on 3-24-15 at 4:30 p.m. when asked about the fall with Resident #1 she stated,Resident #1 was on the secure unit and she was in the dining room in a wheel chair with the alarm on. She had a [MEDICAL CONDITION]; she is constantly trying to get up. The aide was helping Resident # 19 into her chair and the floater had left, I don't know the aides name that remained on the unit. She heard the alarm, went over to the dining room and Resident #1 was already on the floor. She obviously had a fracture, she was left on the floor and 911 was called. She went to the hospital with a [MEDICAL CONDITION]." An interview with CNA K on 3-25-15 at 5:15 p.m. revealed that CNA K was working on the secure unit the afternoon that Resident #1 fell . CNA K stated; "I was working as a CNA on the secure unit. I was the only one there, Resident #1 wanted to sit in a regular chair. I put the chair alarm on the regular chair and Resident #1 sat down, then I went to the bathroom. I heard the alarm and when I came out Resident #1 was on the floor." CNA K stated she stays back in the secure unit and the only time she has another person in the secure unit is if she calls for help. CNA K was asked if she felt she should have called for help when she needed to go to the restroom she stated, "Resident #1 seemed fine, but maybe I should have called for help." CNA K stated there is always only one aide in the secure unit unless they need help. Observation on 3-24-15 at 12:00 p.m. revealed Resident #1 sitting in a geri chair in the dining room of the secure unit. There was no chair alarm or personal alarm on Resident #1's person or chair. The care plan dated 3/15/15 stated that the resident should have a chair alarm. Record review of the additional incident and accident reports for the secure unit revealed that there were 7 additional falls for a total of 19 falls over a four month period in the secure unit from 11-16-15 through 3-15-15 for 5 different residents. Resident #19: Record review of Resident #19 (who resides in the secure unit) medical record revealed an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #19 needed extensive assistance and 2 people for transfers, and dressing. For bathing Resident #19 was totally dependent with one person. Resident #19 is frequently incontinent of bowel and bladder. Resident #19's BIMS score was 3 (severely impaired). Review of the fall risk assessment for Resident #19 on 3-25-15 showed a score of 19 (high risk for falls). Review of Event Nurses Notes (Incident Report) for Resident #19 dated 1/20/15 revealed a witnessed fall. The facility intervention initiated after the fall: vitals and shoes/slip socks. Review of Event Nurses Notes for Resident #19 dated 1/21/15 revealed an un-witnessed fall. The facility intervention initiated after the fall: Pressure alarm (Bed), and encouraged resident to use call light for assist. Review of Event Nurses Notes for Resident #19 dated 2/27/15 revealed a witnessed fall. The report form contained a check box labeled other which was checked, but did not have any interventions written in. Resident #19's care plan dated 1/21/15 showed she is a high risk for falls. Interventions listed for Resident #19 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #19's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; Encourage use of call light and other: staff to anticipate resident needs 2/27/15. Review of Resident #19's Falls Care Plan dated 1/20/15 revealed the facility did not do a fall risk assessment after each fall on 1/20/15 and 1/21/15. Resident #23: Record review of Resident #23's (who resides in the secure unit) medical record stated Resident #23 is an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the annual MDS assessment dated [DATE] showed that Resident #23 needed supervision and set up help for transfer, and eating. Resident #23 needed limited assistance with one person for eating, and dressing. Resident #23 needed physical help with one person for bathing. Resident #23's BIMS score was 2 (severely impaired). Review of the fall risk assessment for Resident #23 on 3-19-15 showed a score of 10 (high risk for falls). Review of Event Nurses Notes dated 12/15/14 revealed an un-witnessed fall. Obstacles noted: blanket/walker. Facility interventions initiated after the fall: monitor regularly and take to the bathroom every 2 hours. Resident #23's care plan showed she is a high risk for falls. Interventions listed for Resident #23 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #23's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; anticipate resident needs 12/15/14. Review of Resident #23's fall care plan dated 12/15/14 revealed the facility did not ensure Resident #23's room was free from clutter as attested in the event nurses note on 12/15/14 that listed a blanket and walker as obstacles. Resident #24: Record review of Resident #24 (who resides in the secure unit) revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record Review of the quarterly MDS dated [DATE] showed that Resident #24 needed extensive assistance with two people for transfer, and dressing. Resident #24 needed extensive assistance with one person for eating and bathing. Resident #24's BIMS score was 00. Resident #24 was frequently incontinent of bowel and bladder. Review of the fall risk assessment for Resident #24 on 1-16-15 showed a score of 14 (high risk for falls). Review of an Event Nurses Note dated 1/16/15 revealed an un-witnessed fall. Obstacles involved; roommates wheelchair. Facility interventions initiated after the fall;low bed, house shoes and non-skid socks. The narrative stated that the roommates wheelchair was left in the way and this is what Resident #24 fell on . Resident #24's care plan dated 1/16/15 showed Resident #24 is a high risk for falls. Interventions listed for Resident #24 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #24's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; other - remove obstacles in room [ROOM NUMBER]/16/15. Review of Resident #24's fall care plan revealed obstacles were not removed from Resident #24's room until after a fall occurred. Resident #25: Record Review of Resident #25 (who resides in the secure unit) revealed that Resident #25 is a [AGE] year old with the following Diagnoses: [REDACTED]. Review of the fall risk assessment for Resident #25 on 1-16-15 showed a score of 20 (high risk for falls). Review of an Event Nurses Note dated 12/14/14 revealed a witnessed fall. No facility initiated interventions after the event were checked. Review of a Nurses Note - Fall (no date on form) for Resident #25 revealed approaches taken by the facility; Body alarm for bed and chair, low bed and wheelchair. Resident #25's care plan dated 12/14/14 showed Resident #25 is a high risk for falls. Interventions listed for Resident #25 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #25's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #25's fall care plan revealed the facility did not perform a fall risk assessment after the 12/14/14 fall. Review of the quarterly MDS dated [DATE] revealed that Resident #25 needed extensive assistance with one person for transfer, and eating. Resident #25 needed extensive assistance with 2 people for dressing. Resident #25 was totally dependent with one person for bathing. Resident #25 is always incontinent of bladder and frequently incontinent of bowel. Resident #25's BIMS score is 3 (severely impaired). Resident #27: Record review of Resident #27's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] stated that Resident #27 requires extensive assistance with one person for transfer, dressing, eating and total dependence with two people for bathing. Resident #27 is always incontinent of urine and frequently incontinent of bowel. Resident #2's BIMS score is 3 (severely impaired). Review of Resident #27's Fall Risk assessment dated [DATE] revealed a score of 10 (high risk for falls). Review of an Event Nurses Note dated 12/4/14 revealed a witnessed fall. There were no interventions initiated by the facility after the fall. Resident #27's care plan dated 12/4/14 showed Resident #27 is a high risk for falls. Interventions listed for Resident #27 include: The following are pre-printed interventions using bullet points: Keep the resident's room free from clutter. Refer to therapy department as needed. Ensure the residents living area has proper lighting. Keep the resident's call light in reach while they are in their room. Fall risk assessment on admit, quarterly, and after a fall. Notify the physician and family of any changes. Resident #27's individually checked fall care plan (beneath the bullet points) revealed the following boxes checked; nothing was checked. Review of Resident #27's fall care plan revealed the facility did not perform a fall risk assessment after the 12/4/14 fall. There were 2 additional fall risk assessments done on 1/19/15 and 3/19/15 that scored Resident #27 a 9 (low risk for falls). During an interview with the DON on 3-25-15 at 4:00 p.m. she was asked about the staffing in the secure unit in regards to falls, she stated there was one CNA on the unit both day and night. They have a float that usually goes back every hour to check in the secure unit. The CNA on the secure unit will call for help if needed. The DON stated she felt like it was adequately staffed. During an interview with the DON on 3-26-15 at 2:35 p.m. the DON was asked about CNA K leaving Resident #1 unattended, and the DON stated that CNA K should not have left Resident #1 unattended. "Our procedure is to call for another staff to come and cover when we go to the bathroom." Review of the staffing sheet for the secure unit showed for March 1 through March 25 there were 14 days with a CNA assigned to float and 7 days where there was not a float assigned at all. On 5 days there was only partial coverage, there was not a float assigned for the entire shift. During a confidential interview with Interviewee on 3-25-15 at 11:10 a.m. Interviewee stated there is only one aide on the secure unit at any time and that is not enough for the type of people they are caring for and how many people they are caring for. Interviewee stated the LVN's assigned to the secure unit do not stay in the unit, and are not aware of the activities going on in the secure unit. During an interview in the secure unit with CNA F on 3-25-14 at 3:10 p.m. she stated she works the 2:00 p.m. to 10:00 p.m. shift. "It is always just myself working with all the residents here. If anyone needs assistance, it leaves everyone else by themselves." During an interview with LVN E on 3-25-15 at 7:00 p.m. she was asked how many aides are in the secure unit, LVN E stated that only one aide works in the secure unit. LVN E said "I stay at the main nurse's station and I pass meds for the secure unit and Hall #6." LVN E works the 6:00 p.m. to 6:00 a.m. shift. During an interview with HA on 3-25-15 at 6:50 p.m. when asked if he worked in the secure unit HA stated. "I pass ice; I don't provide any personal care." During an interview with CNA L on 3-25-15 at 6:55 p.m. CNA L stated, "I work the 2:00 p.m. to 10:00 p.m. shift in the secure unit. We have a float and they help if needed." The facility Administrator was notified on 3/25/15 at 5:50 p.m. that an IJ situation had been identified due to the above failures. The facility's Plan of Removal was provided by the Administrator on 3/26/15 at 10:50 am. The Plan of Removal was accepted at 11:11 a.m. on 3/26/15. The facility took the following actions to remove the immediacy of the IJ: 1. Two staff members will be on the secure unit for each of the three shifts; with 2 staff members on the secure unit at all times - one staff member can also be sent to notify the charge nurse if extra intervention is needed. 2. The staff will be immediately in-serviced on how to reach the nurse when needed i.e. phone call to the desk, intercom to page a nurse to the secure unit, and walkie-talkies for communication with the nurse assigned to the secured unit. 3. All staff that work on the secure unit will be in-serviced before they start their next shift on: a. falls and fall prevention b. how to care for a resident with a hip injury i.e. turning and transfers c. verbal and non-verbal pain indications and pain assessments 4. All residents in the secured unit and the rest of the facility will be assessed for pain immediately on 3/26/15, and pain management will be initiated if needed per physician orders. All residents will have a pain assessment performed upon admission, quarterly, with a significant change, and upon resident complaint of pain. 5. All residents will have the current Fall Risk Assessment reviews and updated as needed on 3/26/15, and care plans will be updated. 6. Residents with multiple falls will have new interventions considered and implemented of appropriate as the care plan is updated as needed. (See attached Event Nurses Note). 7. The DON will review all incidents to make sure appropriate interventions are updated and in place, as well as care plans updated as needed. 8. A review of the last 30 days of event notes of falls will be completed to check that the appropriate interventions are in place. 9. The plan will be reviewed by the QAPI committee weekly for 4 weeks, and then monthly for 90 days. Observations on 3/26/15 at 1:40 p.m. and 4:00 p.m. showed that the locked unit was staffed with two staff members. One of the two CNA's in the unit carried a walkie-talkie. The LVN assigned to the unit (who is not present on the unit unless needed) was also wearing a walkie-talkie for communication with the CNA located inside the secure unit. Review of staff in-service records show that 56 staff members were in-serviced on two staff in secure unit at all times, falls, fall prevention, pain assessments and non-verbal signs of pain, and repositioning and transferring of residents with recent [MEDICAL CONDITION] on 3/25/15 and 3/26/15 by the ADON. Review of the in-service provided by the PT on 3/26/15 on the transfers and care specific to the post [MEDICAL CONDITION] resident was attended by 45 staff members. Interviews with 12 different staff members from 1:15 p.m. to 1:40 p.m. on 3/26/15 revealed that they had been in-serviced on the above. In an additional interview with CNA O on 3/26/15 at 4:00 p.m. it was stated that the aide would attend an in-service presented by the PT that afternoon. Record review of the pain assessments of each of the ten residents residing in the secured unit show the assessments were all completed on 3/25/15. Record review of the fall assessments for each of the ten residents in the secured unit were completed on 3/26/15. On 3/26/15 at 11:11 a.m. the CA and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm, and a scope of pattern that is not immediate jeopardy die to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. The CMS Resident Census and Condition of Residents obtained on 3-24-15 documented a Census of 84. There were 10 residents residing in the secured unit and six of these residents were at high risk for falls.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable, physical, mental and psychosocial well-being for 2 of 10 Residents (Resident #1 and #14) reviewed for quality of care when; 1. The facility failed to provide Resident #1 pain medication on the night she returned to the facility post [MEDICAL CONDITION] for the 12 hours from 8:00 p.m. until 8:25 a.m. the next morning; even when it was requested. 2. The facility failed to assess Resident #1 for pain prior to providing incontinent care. During incontinent care Resident #1's left foot (the side of the [MEDICAL CONDITION]) was crossed over her right foot and no abduction pillow was placed between her legs. Resident #1 screamed in pain when the aides tried to roll her to the side. 3. The facility failed to provide training for care and services post [MEDICAL CONDITION] for staff providing care for Resident #1 so that they would not inflict additional injury to her. 4. The facility failed to transport Resident #14 to a second sleep study to try [MEDICAL CONDITION]. The original sleep study recommended a repeat sleep study with a trial of positive airway pressure or bi-level positive airway pressure as soon as possible. The subsequent test was never completed. The facility's failure to provide the necessary care and services affected Resident #1 when pain medication was denied to Resident #1 over a period of hours, as well as prior to incontinent care where Resident #1 had to be re-positioned for care. The facility's failure to train staff on care and handling of residents after hip surgery resulted in Resident #1 sustaining additional pain during incontinent care. This failure to address pain affects the other 9 residents on the secure unit of not having their pain addressed thereby preventing them from attaining or maintaining their highest physical, mental and psychosocial well-being. The facility's failure to follow-up with the additional sleep study test could result in Resident #14 not being able to maintain adequate blood oxygen levels, causing [MEDICAL CONDITION] (a potentially life-threatening condition) and could affect the other 83 residents of the facility needing physician ordered testing that was not accomplished thereby preventing them from reaching their highest physical, mental and psychosocial well-being. Findings include: Resident #1: Record review of Resident #1's medical record revealed a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 2 (severely impaired) and required extensive assistance with two people for transfer, bathing, and dressing. Resident #1 needed extensive assistance from one person to assist for eating and hygiene. Resident #1 was frequently incontinent of bowel and always incontinent of bladder. There was a care plan stating Resident #1 was on [MEDICATION NAME] for pain and this was initiated on 1-8-15. Resident #1' care plan for pain was not updated when Resident #1 returned to the facility on 3-19-15 post [MEDICAL CONDITION]. There was no care planning for Resident #1 for the post [MEDICAL CONDITION] for; positioning, moving, or transferring Resident #1. Observation on 3-24-15 at 12:00 p.m. revealed Resident #1 sitting in a geri chair in the dining room of the secure unit. There was no chair alarm or personal alarm on Resident #1's person or chair. The fall care plan for Resident #1 updated on 1-18-15 states, "Educate staff to stay with resident while up in wheelchair." During a confidential interview on 3-25-15 at 11:10 a.m. interviewee stated that Resident #1 came back from the hospital post hip repair on 3-19-15 and did not receive any pain medication through the night starting on 3-19-15 and into the morning of 3-20-15. Interviewee stated Resident #1 was getting pain medication every 4 hours while in the hospital. Interviewee stated there is only one aide on the secure unit at any time and that is not enough for the type of people they are caring for and how many people they are caring for. Interviewee stated that Resident #1 was moaning and yelling. Interviewee stated the LVN's assigned to the secure unit do not stay in the unit and are not aware if someone needs pain medication. Interviewee stated the aide was asked about pain medication for Resident #1 and the Interviewee was told that the nurse was in the foyer and CNA stated she couldn't leave the unit and interviewee would have to go to the foyer and find the nurse. No call was made to the nurse by the CNA assigned to the unit. Interviewee stated the nurse did not come back to the secure unit during the evening/night. Review of the narcotic log for [MEDICATION NAME] showed it was given to Resident #1 on 3-19-15 at 8:00 p.m. and not again until 8:24 a.m. on 3-20-15. Record review of the facility Individual Control Drug Record showed the order for pain medication for Resident #1 was [MEDICATION NAME] 50 mg every 4 hours as needed. Resident #1 arrived back at the facility following hip repair on 3-19-15 at 11:30 a.m. There was no pain assessment sheet filled out on Resident #1's return to the facility on [DATE]. The most current pain assessment form is 3-25-15, 7 days after coming back to the facility after surveyor intervention. Observation of incontinent care on 3-25-15 at 3:15 p.m. in the secure unit revealed Resident #1 attended by CNA's J and F performing incontinent care. Resident #1 was transferred by gait belt onto the bed. When aides began to provide incontinent care, CNA's crossed Resident #1's left leg over the right leg at the ankle (Resident #1 is just 5 days post-op for a [MEDICAL CONDITION]) to roll her to the side. Resident #1 screamed out in pain. Both CNA J and F were told by surveyor to stop moving Resident #1. They were asked if they knew how to move a fresh hip replacement? They both stated they had not been trained. Surveyor went out into the dining area of the secure unit and had LVN C come into the room and asked her how to move a fresh hip replacement, she stated "Obviously not like this", pointing to Resident #1's crossed ankles. LVN C said they would get Resident #1 some pain medication and then try to provide incontinent care again. During an interview with the DON on 3-25-15 at 4:00 p.m. she was asked about the lack of education in regard to transferring and moving a resident with a recent surgical repair of the hip. The DON stated there was no care plan specifically for Resident #1 on how to care for a resident with a new hip repair. The DON stated she had not educated the staff on post [MEDICAL CONDITION] care, but will educate the staff on transfer and rolling Resident #1 and how to do this. During an interview with PT on 3-26-15 at 1:30 p.m. she was asked how she trained staff after Resident was improperly moved during incontintent care. PT said I am teaching them that when the resident is lying down to roll them to the unaffected side with a pillow between the legs not bent past 90 degress. Resident #14: During a group interview on 3-24-15 at 3:30 p.m. Resident #14 voiced concerns about having a sleep study done and never receiving the [MEDICAL CONDITION] Machine. Review of the clinical record for Resident #14 shows a [AGE] year old with an admission date of [DATE] with a re-admission date of [DATE]. She had the following Diagnoses: [REDACTED]. Review of the Quarterly MDS dated [DATE] shows that she requires assistance with transfers, ambulation, and eating. She is incontinent of bowel and bladder. Record review of Resident #14's medical record showed a sleep study was completed on 11-6-14. The report showed that Resident #14 had significant snoring and severe obstructive sleep apnea syndrome with oxygen desaturations to a minimum of 62%. The recommendation was for the sleep study to be repeated with a trial of positive airway pressure breathing or bi-level positive airway pressure as soon as possible. A sticky note on the sleep study report said, repeat as recommended, order written. During an interview with LVN C on 3-25-15 at 10:40 a.m. she was asked if the second sleep study had been completed for Resident #14. LVN C said she called the facility where the sleep study had been done and they told her they have no record of her returning for the second sleep study. LVN C stated that their transportation aide remembers taking her to the appointment. LVN C was asked if she could provide surveyor with log of signing the resident out for the study, or a copy of the transportation log. LVN C came to surveyor and stated the additional sleep study order had been and will be scheduled. During an interview with the DON on 3-25-15 at 11:00 a.m. she was asked about the sleep study for Resident #14, the DON stated, I know she had a sleep study, I will check on the [MEDICAL CONDITION]. The DON never returned with any proof of this study being completed. There was no policy and procedure provided to surveyors on following recommendation on further testing. Review of the policy and Procedure provided by the facility for Secure Care Environment Staffing Requirements stated: The Secure Care Environment will provide therapeutic staffing to meet the distinct needs of residents with wandering and dementia related disorders. Staffing guidelines will provide residents with consistent staff members that promote an activity intensive environment specifically designed to meet the individual needs of the residents. Employees will encourage maximum levels of independence while providing safety and security. Licensed staff will be maintained and assigned to the Secure Care Environment. Policy: 1. The Secure Care environment will employ licensed nurses and certified nurse's aides for direct patient care. The Secure Environment will be staffed to meet the needs of each resident. The facility provided policy and procedure for Pain Management, Assessment Scale stated: Policy: Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications and comfort measures, and all available resources for the facility. Procedure: 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. The nurse may use the Pain Assessment Tool to complete the resident's complaint of pain. The completed tool will be placed in the resident's clinical record. 2. Administer pain medications as prescribed. Monitor and record medications effectiveness and side effects. 7. Help resident into a comfortable position and use pillows to splint or support painful areas as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain. The CMS Resident Census and Condition of Residents obtained on 3-24-15 documented a Census of 84.

Based on interviews and record review, it was determined that for 2 of 20 sampled residents (Residents #1 and #2), reviewed for pain management and reciept of their medicaions, the facility failed to provide appropriate care and services consistent with recognized standards of practice to attain the residents' highest practicable physical, mental and psychosocial well-being: - Resident #1 had orders for Schedule II medication, [MEDICATION NAME]. The facility failed to acquire a refill and administer the medication, which resulted in Resident #1's transport to a local ED where he recieved an IM injection of [MEDICATION NAME] for relief of severe pain. Resident #1 did not recieve his scheduled [MEDICATION NAME] for a total of 5 days. - Resident #2 tested positive for a bacterial infection in his urine. The facility failed to obtain and administer antibiotics for Resident #2. Resident #2 complained of worsening symptoms of severe pain upon urination. Resident #2 did not recieve the antibiotics for 3 days following the facility's reciept of the positive lab results. Failure to provide Residents #1 and #2 with appropriate treatment and care resulted in pain and functional decline, and placed the remaining sampled residents at risk of not attaining their highest possible level of functional well-being by not receiving appropriate pain management and physician ordered treatments. The evidence is as follows: Resident #1: Review of the face sheet documented Resident #1 was originally admitted to the facility on [DATE] with a readmission date of [DATE]. It documented Resident #1 was [AGE] years of age. [DIAGNOSES REDACTED]. Review of the MDS admission assessment, dated 5/24/12, documented Resident #1 required limited 1-person assistance with transfers and most activities of daily living, and utilized a walker for mobility. The assessment documented additional [DIAGNOSES REDACTED]. It documented Resident #1 received scheduled pain mediction and experienced continual pain which limited day to day activities and made sleeping at night difficult. At the time of the assessment Resident #1 rated the pain as severe, and intensity as a nine over the previous five-day look-back period, with zero being no pain and ten the worst pain imaginable. Review of the comprehensive plan of care documented on 5/24/12 that Resident #1 had sufferred lower back and neck pain for years. The care plan was updated on 7/25/12, and documented daily complaints of severe pain which Resident #1 rated as an eight to nine in severity. Review of physician's telephone orders, dated 6/7/12, documented orders by Physician "H" for scheduled [MEDICATION NAME] ER 15 mgs., TID and [MEDICATION NAME] ER 30 mgs, TID (total dose 45 mgs., TID). Review of physician's triplicate orders dated 7/12/12, by Physician "H" documented orders for scheduled [MEDICATION NAME] ER 15 mgs., take one tablet TID and [MEDICATION NAME] ER 30 mgs., take one tabet TID. Additional review of physician's orders [REDACTED]. - 6/2/12, PCP changed from Physician "H" to Physician "I". - 6/8/12, PCP again changed from Physician "H" to Physician "I". - 7/17/12, PCP changed from Physician "I" to Physician "H". - 7/31/12, PCP changed from Physician "H" to Physician "I". Review of nursing notes dated 8/18/12 at 0600 (6:00 a.m.), by LVN "A"documented Resident #1's family arrived at the facility to transport Resident #1 to a local hospital's ED by private vehicle following concerns the facility had not obtained or administered Resident #1's scheduled [MEDICATION NAME] and Resident #1 was experiencing pain. The notes continued at 0720 (7:20 a.m.), that a telephone call to the pharmacy confirmed orders had not yet been received by the pharmacy for Resident #1's scheduled [MEDICATION NAME]. The notes documented a telephone call to the PA, who refused to contact Physician "I" or an on-call physician in order to obtain a triplicate order for the [MEDICATION NAME] (PAs are unable to complete triplicate orders for Schedule II medications). The notes documented Physician "I" was then contacted on his direct line at which time Physician "I" stated he would find another physician to fax another triplicate order to the pharmacy. Review of the MAR for August, 2012, documented Resident #1 was not administered ordered [MEDICATION NAME] 15 mgs. and 30 mgs. TID as scheduled after 8/12/12 at 0300 (3:00 a.m.) through 8/17/12 (five days for a total of 17 missed doses). Review of a Medication Error Form dated 8/18/12, documented Resident #1's [MEDICATION NAME] ER 45 mgs., ordered for TID at 0300, 1100 and 1900 had not been administered starting with the 8/12/12 1100 dose because the medication was not available. Review of the Emergency Department Patient Visit Information sheet dated 8/18/12 documented chronic back pain and instructions for the facility to make all attempts to obtain Resident #1's pain medication prior to the next scheduled dose or ensure Resident #1 received the pain medication. Review of the facility provided list of residents who were prescribed narcotics, received on 8/19/12, documented a total of 33 residents were prescribed narcotic medications, 3 of whom were prescribed [MEDICATION NAME]. Review of Nursing Report Sheets documented no evidence that Resident #1's need for [MEDICATION NAME] had been communicated between nursing staff during shift change reports throughout the period of time Resident #1 was not being adminisitered the scheduled [MEDICATION NAME]. Review of Twenty-Four Hour Report sheets resulted in no documented evidence that Resident #1's need for [MEDICATION NAME] had been communicated among nursing staff during shift changes. During an interview on 8/19/12 at 4:10 p.m., the DON said Resident #1 was administered his last available dose of scheduled [MEDICATION NAME] on 8/12/12 at 0300 (3:00 a.m.). In addition, the DON said licensed nurses were responsible for ordering medications seven days prior to administration of the last dose, adding Resident #1's [MEDICATION NAME] should have been ordered on [DATE]. The DON said she was notified of Resident #1's [MEDICATION NAME] shortage on 8/18/12 at 0600 (6:00 a.m.) by LVN "A". The DON said the facility's failure to obtain Resident #1's [MEDICATION NAME] in a timely manner was the result of a "huge failure in communication" by nurses who failed to pass on during shift change reports that the orders had not yet been obtained. The DON said multiple nurses assumed other nurses had already taken care of obtaining the orders, adding a total of seven nurses had worked at the facility who were responsible for ensuring Resident #1's [MEDICATION NAME] was obtained (LVNs "A", "B", "C", "D", "E", "F" and "G") during the time the medication was unavailable. The DON said all nurses had been in-serviced regarding medication procedures as of 8/19/12 at 2:00 p.m. The DON said the in-service addressed proper procedures for obtaining medication orders, communicating medication orders to the pharmacy and notifying the DON of any medication issues, to include failure to obtain orders for medications or failure to acquire the medications. During an interview on 8/19/12 at 5:40 p.m., Resident #1 said the pain was severe on 8/18/12, and rated the pain as a ten, with zero being no pain and ten being the worst possible pain, during the time of transfer by a family member to a local ED for pain relief. During a telephone interview on 8/19/12 at 5:10 p.m., Physician "I" said he faxed two orders to the pharmacy on the morning og 8/17/12, one for Resident #1's scheduled [MEDICATION NAME] ER 15 mgs., TID, and one for Resident #1's scheduled [MEDICATION NAME] ER 30 mgs., TID, adding the pharmacy later advised him they never received the order for the 15 mg. scheduled [MEDICATION NAME] ER. Physician "I" also said he had not been aware Resident #1 was his patient until the morning og 8/17/12". During an interview on 8/21/12 at 9:30 a.m., LVN "B" said nurses had not been passing on information during shift changes regarding the neeed for Resident #1's [MEDICATION NAME] orders to be refilled. LVN "B" said she was advised by Physician "H's" office on 8/15/12 that Physician "H" was no longer Resident #1's physician, adding Physician "I" ordered the [MEDICATION NAME] on 8/17/12. During a telephone interview on 8/21/12 at 12:05 p.m., LVN "D" said she had faxed a request for Resident #1's [MEDICATION NAME] to be refilled to the wrong physician (Physician "H") on 8/12/12, adding she was unaware Physician "H" was not Resident #1's physician at that time. During a telephone interview on 8/21/12 at 2:30 p.m., LVN "C" said she recalled faxing the 7/12/12 triplicate orders written by Physician "H" for Resident #1's [MEDICATION NAME] to the pharmacy on 8/5/12, adding she was unaware at that time that she should have been faxing orders from Physician "I" who was actually Resident #1's PCP at that time. LVN "C" said she faxed the orders to the wrong physician, adding there had been a communication problem between the nurses regarding acquisition of the physicians' orders and the [MEDICATION NAME]. She said the pharmacy did not honor the July order because it had been filled during July, and was being re-submitted for refill during August. Resident #2: Review of the face sheet documented an admission date of [DATE], with a re-admission date of [DATE]. Resident#2 was [AGE] years of age. [DIAGNOSES REDACTED].It documented Resident #2 was allergic to [MEDICATION NAME]. Review of the MDS admission assessment dated [DATE] documented Resident #2 had a UTI within thirty days previous to the assessment.It further documented chronic, frequent, moderate pain, described by the resident as a seven, with zero being no pain and ten being the worst imaginable pain. It documented the pain limited Resident #2's day to day activities. Review of physician's telephone orders dated 8/15/12 documented orders for a UA. Review of laboratory results dated [DATE] at 12:37 p.m., documented gram negative bacilli, E. Coli (Escherichia coli are aerobic inhabitants of the large intestines that can cause infection when they invade sterile sites such as the urinary tract, per the Merck Manual for Health Care Professionals, obtained on-line on 9/6/12). Review of physician's telephone orders dated 8/19/12 at 1835 (6:35 p.m., after surveyor entered the facility) documented orders had been obtained [MEDICATION NAME](an antibiotic), 500 mgs., PO, BID x's five days. This was three days following receipt by the facility of Resident #2's lab results. Review of Nursing Report Sheets documented no evidence that Resident #2's need for ABT had been communicated between nursing staff during shift change reports. Review of Twenty-Four Hour Report sheets resulted in no documented evidence that Resident #2's need for ABT had been communicated among nursing staff during shift changes. During an interview on 8/19/12 at 5:45 p.m., Resident #2 said medications had not yet been administered for a UTI which the facility had been aware of for the past several days (since 8/16/12). Resident #2 described burning pain upon urination and rated the pain as a nine, with zero being no pain and ten being the worst imaginable pain. During a subsequent interview on 8/2112 at 11:15 a.m., Resident #2 descibed the pain upon urination as "excruciating" and said it mde the resident want to "turn the entire bathroom over" when urinating. During an interview on 8/19/12 at 6:15 p.m. LVN "A" said Resident #2 had first begun complaining of pain during urination on 8/14/12, adding a UA sample had been obtained on 8/15/12, with results obtained on 8/16/12. LVN "A" said there had been no follow-up by nurses, adding it was on her "to do" list following the interview with surveyor. LVN "A" said she was unsure whether or not the DON had been made aware Resident #2 had not yet been administered ABT. LVN "A" acknowedged she had just received additional training within the previous twenty-four hours, that nurses were to report all issues related to not acquiring residents' medications to the DON. LVN "A" acknowledged she had failed to notify the DON regarding Resident #2 having not yet begun ABT. LVN "A" said "I'm sorry, I don't know why I did not tell her (DON)". During an interview on 8/19/12 at 6:20 p.m., the DON acknowledged she had not been aware Resident #2 had received no ABT since his 8/16/12 lab results indicated a bacterial infection. The DON said "I'll take care of it". During a subsequent interview on 8/21/12 at 10:30 a.m., the DON said it was standard practice that ABTs were initiated within four hours of obtaining ABT orders, which were to be obtained immediatly following receipt of lab results. The DON said she was not aware of any orders for Resident #2 to begin ABT following the 8/16/12 lab results until after the facility had been made aware by the state surveyor on the evenong of 8/19/12. During an interview on 8/19/12 at 7:20 p.m., the ADON said orders had been obtained for Resident #2 to begin ABT with the first dose having been adminstered on 8/19/12 at 1840 (6:40 p.m.). This was 2 hours and forty minutes following surveyor's entrance to the facility, and three days following receipt of the positive UA lab results. Review of the Resident Work List provided by the facility on 8/19/12 documented 63 residents.

Based on interviews and record review, it was determined that for 2 of 20 sampled residents (Residents #1 and #2) reviewed for pain management and reciept of their medicaions, the facility failed to provide pharmaceutical services: - Resident #1 had orders for Schedule II Morphine. The facility failed to acquire a refill and administer the medication, which resulted in Resident #1's transport to a local ER where he recieved an IM injection of Morphine for relief of severe pain. Resident #1 did not recieve his scheduled Morphine for a total of 5 days. - Resident #2 tested positive for a bacterial infection in his urine. The facility failed to obtain and administer antibiotics for Resident #2 until brought to attention by the state surveyor. Resident #2 complained of worsening symptoms of severe pain upon urination. Resident #2 did not recieve the antibiotics for 3 days following the facility's reciept of the positive lab results. Failure to acquire and administer medications resulted in prolonged pain and anxiety for the residents, and placed the remaining sampled residents at risk of not attaining their highest possible level of functional well-being by not receiving appropriate pain management and physician ordered treatments and safe and effective benefits from thier medication regimens. The evidence is as follows: Resident #1: Review of the face sheet documented Resident #1 was originally admitted to the facility on [DATE] with a readmission date of [DATE]. It documented Resident #1 was [AGE] years of age. [DIAGNOSES REDACTED]. Review of the MDS admission assessment, dated 5/24/12, documented Resident #1 required limited 1-person assistance with transfers and most activities of daily living, and utilized a walker for mobility. The assessment documented additional [DIAGNOSES REDACTED]. It documented Resident #1 received scheduled pain mediction and experienced continual pain which limited day to day activities and made sleeping at night difficult. At the time of the assessment Resident #1 rated the pain as severe, and intensity as a nine over the previous five-day look-back period, with zero being no pain and ten the worst pain imaginable. Review of the comprehensive plan of care documented on 5/24/12 that Resident #1 had sufferred lower back and neck pain for years. The care plan was updated on 7/25/12, and documented daily complaints of severe pain which Resident #1 rated as an eight to nine in severity. Review of physician's telephone orders, dated 6/7/12, documented orders by Physician "H" for scheduled Morphine ER 15 mgs., TID and Morphine ER 30 mgs, TID (total dose 45 mgs., TID). Review of physician's triplicate orders dated 7/12/12, by Physician "H" documented orders for scheduled Morphine ER 15 mgs., take one tablet TID and Morphine ER 30 mgs., take one tabet TID. Additional review of physician's orders [REDACTED]. - 6/2/12, PCP changed from Physician "H" to Physician "I". - 6/8/12, PCP again changed from Physician "H" to Physician "I". - 7/17/12, PCP changed from Physician "I" to Physician "H". - 7/31/12, PCP changed from Physician "H" to Physician "I". Review of nursing notes dated 8/18/12 at 0600 (6:00 a.m.), by LVN "A"documented Resident #1's family arrived at the facility to transport Resident #1 to a local hospital's ED by private vehicle following concerns the facility had not obtained or administered Resident #1's scheduled Morphine and Resident #1 was experiencing pain. The notes continued at 0720 (7:20 a.m.), that a telephone call to the pharmacy confirmed orders had not yet been received by the pharmacy for Resident #1's scheduled Morphine. The notes documented a telephone call to the PA, who refused to contact Physician "I" or an on-call physician in order to obtain a triplicate order for the Morphine (PAs are unable to complete triplicate orders for Schedule II medications). The notes documented Physician "I" was then contacted on his direct line at which time Physician "I" stated he would find another physician to fax another triplicate order to the pharmacy. Review of the MAR for August, 2012, documented Resident #1 was not administered ordered Morphine 15 mgs. and 30 mgs. TID as scheduled after 8/12/12 at 0300 (3:00 a.m.) through 8/17/12 (five days for a total of 17 missed doses). Review of a Medication Error Form dated 8/18/12, documented Resident #1's Morphine ER 45 mgs., ordered for TID at 0300, 1100 and 1900 had not been administered starting with the 8/12/12 1100 dose because the medication was not available. Review of the Emergency Department Patient Visit Information sheet dated 8/18/12 documented chronic back pain and instructions for the facility to make all attempts to obtain Resident #1's pain medication prior to the next scheduled dose or ensure Resident #1 received the pain medication. Review of the facility provided list of residents who were prescribed narcotics, received on 8/19/12, documented a total of 33 residents were prescribed narcotic medications, 3 of whom were prescribed Morphine. Review of Nursing Report Sheets documented no evidence that Resident #1's need for Morphine had been communicated between nursing staff during shift change reports throughout the period of time Resident #1 was not being adminisitered the scheduled Morphine. Review of Twenty-Four Hour Report sheets resulted in no documented evidence that Resident #1's need for Morphine had been communicated among nursing staff during shift changes. During an interview on 8/19/12 at 4:10 p.m., the DON said Resident #1 was administered his last available dose of scheduled Morphine on 8/12/12 at 0300 (3:00 a.m.). In addition, the DON said licensed nurses were responsible for ordering medications seven days prior to administration of the last dose, adding Resident #1's Morphine should have been ordered on [DATE]. The DON said she was notified of Resident #1's Morphine shortage on 8/18/12 at 0600 (6:00 a.m.) by LVN "A". The DON said the facility's failure to obtain Resident #1's Morphine in a timely manner was the result of a "huge failure in communication" by nurses who failed to pass on during shift change reports that the orders had not yet been obtained. The DON said multiple nurses assumed other nurses had already taken care of obtaining the orders, adding a total of seven nurses had worked at the facility who were responsible for ensuring Resident #1's Morphine was obtained (LVNs "A", "B", "C", "D", "E", "F" and "G") during the time the medication was unavailable. The DON said all nurses had been in-serviced regarding medication procedures as of 8/19/12 at 2:00 p.m. The DON said the in-service addressed proper procedures for obtaining medication orders, communicating medication orders to the pharmacy and notifying the DON of any medication issues, to include failure to obtain orders for medications or failure to acquire the medications. During an interview on 8/19/12 at 5:40 p.m., Resident #1 said the pain was severe on 8/18/12, and rated the pain as a ten, with zero being no pain and ten being the worst possible pain, during the time of transfer by a family member to a local ED for pain relief. During a telephone interview on 8/19/12 at 5:10 p.m., Physician "I" said he faxed two orders to the pharmacy on the morning og 8/17/12, one for Resident #1's scheduled Morphine ER 15 mgs., TID, and one for Resident #1's scheduled Morphine ER 30 mgs., TID, adding the pharmacy later advised him they never received the order for the 15 mg. scheduled Morphine ER. Physician "I" also said he had not been aware Resident #1 was his patient until the morning og 8/17/12". During an interview on 8/21/12 at 9:30 a.m., LVN "B" said nurses had not been passing on information during shift changes regarding the neeed for Resident #1's Morphine orders to be refilled. LVN "B" said she was advised by Physician "H's" office on 8/15/12 that Physician "H" was no longer Resident #1's physician, adding Physician "I" ordered the Morphine on 8/17/12. During a telephone interview on 8/21/12 at 12:05 p.m., LVN "D" said she had faxed a request for Resident #1's Morphine to be refilled to the wrong physician (Physician "H") on 8/12/12, adding she was unaware Physician "H" was not Resident #1's physician at that time. During a telephone interview on 8/21/12 at 2:30 p.m., LVN "C" said she recalled faxing the 7/12/12 triplicate orders written by Physician "H" for Resident #1's Morphine to the pharmacy on 8/5/12, adding she was unaware at that time that she should have been faxing orders from Physician "I" who was actually Resident #1's PCP at that time. LVN "C" said she faxed the orders to the wrong physician, adding there had been a communication problem between the nurses regarding acquisition of the physicians' orders and the Morphine. She said the pharmacy did not honor the July order because it had been filled during July, and was being re-submitted for refill during August. Resident #2: Review of the face sheet documented an admission date of [DATE], with a re-admission date of [DATE]. Resident#2 was [AGE] years of age. [DIAGNOSES REDACTED].It documented Resident #2 was allergic to penicillin. Review of the MDS admission assessment dated [DATE] documented Resident #2 had a UTI within thirty days previous to the assessment.It further documented chronic, frequent, moderate pain, described by the resident as a seven, with zero being no pain and ten being the worst imaginable pain. It documented the pain limited Resident #2's day to day activities. Review of physician's telephone orders dated 8/15/12 documented orders for a UA. Review of laboratory results dated [DATE] at 12:37 p.m., documented gram negative bacilli, E. Coli (Escherichia coli are aerobic inhabitants of the large intestines that can cause infection when they invade sterile sites such as the urinary tract, per the Merck Manual for Health Care Professionals, obtained on-line on 9/6/12). Review of physician's telephone orders dated 8/19/12 at 1835 (6:35 p.m., after surveyor entered the facility) documented orders had been obtained for Cipro (an antibiotic), 500 mgs., PO, BID x's five days. This was three days following receipt by the facility of Resident #2's lab results. Review of Nursing Report Sheets documented no evidence that Resident #2's need for ABT had been communicated between nursing staff during shift change reports. Review of Twenty-Four Hour Report sheets resulted in no documented evidence that Resident #2's need for ABT had been communicated among nursing staff during shift changes. During an interview on 8/19/12 at 5:45 p.m., Resident #2 said medications had not yet been administered for a UTI which the facility had been aware of for the past several days (since 8/16/12). Resident #2 described burning pain upon urination and rated the pain as a nine, with zero being no pain and ten being the worst imaginable pain. During a subsequent interview on 8/2112 at 11:15 a.m., Resident #2 descibed the pain upon urination as "excruciating" and said it mde the resident want to "turn the entire bathroom over" when urinating. During an interview on 8/19/12 at 6:15 p.m. LVN "A" said Resident #2 had first begun complaining of pain during urination on 8/14/12, adding a UA sample had been obtained on 8/15/12, with results obtained on 8/16/12. LVN "A" said there had been no follow-up by nurses, adding it was on her "to do" list following the interview with surveyor. LVN "A" said she was unsure whether or not the DON had been made aware Resident #2 had not yet been administered ABT. LVN "A" acknowedged she had just received additional training within the previous twenty-four hours, that nurses were to report all issues related to not acquiring residents' medications to the DON. LVN "A" acknowledged she had failed to notify the DON regarding Resident #2 having not yet begun ABT. LVN "A" said "I'm sorry, I don't know why I did not tell her (DON)". During an interview on 8/19/12 at 6:20 p.m., the DON acknowledged she had not been aware Resident #2 had received no ABT since his 8/16/12 lab results indicated a bacterial infection. The DON said "I'll take care of it". During a subsequent interview on 8/21/12 at 10:30 a.m., the DON said it was standard practice that ABTs were initiated within four hours of obtaining ABT orders, which were to be obtained immediatly following receipt of lab results. The DON said she was not aware of any orders for Resident #2 to begin ABT following the 8/16/12 lab results until after the facility had been made aware by the state surveyor on the evenong of 8/19/12. During an interview on 8/19/12 at 7:20 p.m., the ADON said orders had been obtained for Resident #2 to begin ABT with the first dose having been adminstered on 8/19/12 at 1840 (6:40 p.m.). This was 2 hours and forty minutes following surveyor's entrance to the facility, and three days following receipt of the positive UA lab results. Review of the Resident Work List provided by the facility on 8/19/12 documented 63 residents.

Based on record review and interviews, it was determined that for 16 of 20 sampled residents (Residents #1-16), reviwed for proper acquistion of their prescribed medications, the facility was not managed in a manner to effectively and efficiently utilize resources in order to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident: - The DON failed to effectively supervise and monitor nursing staff responsible for obtaining medication orders and acquiring medications following instruction and training the nurses regarding pharmaceutical services. - The ADM failed to supervise, monitor and consult with the DON to ensure the 16 residents received their prescribed medications. This failure placed the residents at risk of potentially serious physical consequences by placing them at risk of not recieving medications as prescribed. The evidence is as follows: Review of a facility provided list of Residents #1 through 16 with the DON present, revealed the following medications had not been ordered in a timely manner: Resident #1- [MEDICATION NAME] ER 15 mgs TID and 30 mgs TID. The resident missed 17 doses and was transported to a local ED for pain relief as a result of failure by the facility to obtain the medication. Resident #2- [MEDICATION NAME]. In addition, the facility failed to order an antibiotic,[MEDICATION NAME] 3 days (6 doses), following lab results which identified a UTI. Resident #3- Nicoine patch. Resident #4-[MEDICATION NAME], KCL, [MEDICATION NAME] sprinkles, [MEDICATION NAME] and [MEDICATION NAME]. Resident #5- [MEDICATION NAME], Alendronate Resident #6- Ramipril. Resident #7-Primadone Resident #8- Folic acid, [MEDICATION NAME] nasal spray and [MEDICATION NAME]. Resident #9- [MEDICATION NAME]. Resident #10- [MEDICATION NAME] and [MEDICATION NAME]. Resident #11- [MEDICATION NAME]. Resident #12- Fosomax, potassium, Guifenesin, [MEDICATION NAME]. Resident #13- [MEDICATION NAME]. Resident #14- [MEDICATION NAME]. Resident #15- Guifenesin, [MEDICATION NAME], Robafin, [MEDICATION NAME], and Loparamide. Resident #16- [MEDICATION NAME] inhaler, [MEDICATION NAME], and [MEDICATION NAME]. Review of the facility provided document titled Job Description Director of Nursing (no date), documented : - Accountable for nursing compliance, excellence, and delivery of resident care services in adherence with the company, local, state and federal regulations. - Manage nursing staff through appropriate hiring, training, evaluation, assignment, and delegation of duties, within budget and resident census guidelines. During an interview on 8/19/12 at 4:10 p.m., the DON said licensed nurses were responsible for ordering medications seven days prior to administration of the last dose. The DON said all nurses had been in-serviced regarding medication procedures as of 8/19/12 at 2:00 p.m.The DON said numerous nurses had failed to effectively comunicate the need for residents' medications to be re-ordered, and referred to the situation as a "huge communication failure". The DON said all nursing staff had been inserviced as of 8/19/12 at 2:00 p.m. regarding pharmacy services. The DON said the in-service addressed proper procedures for obtaining medication orders, communicating medication orders to the pharmacy and notifying the DON of any medication issues, to include failure to obtain orders for medications or failure to acquire the medications. During an interview on 8/19/12 at 4:15 p.m., the ADM said he had been unaware there were problems in the area of pharmacy services until it was brought to his attention by the DON on 8/18/12 at which time it was reported to him that Resident #1 had been transported to a local ED for pain relief after not having been administered his scheduled [MEDICATION NAME] for several days. He said an internal investigation ientified the remainng residents (#2 through #16) on 8/19/12. During an interview on 8/19/12 at 5:45 p.m., Resident #2 said ABT medications had not yet been administered for a UTI which the facility had been aware of for the past several days (since 8/16/12).This had not been noted on the facility provided list of residents whos medications had not been ordered timely. During an interview on 8/19/12 at 6:15 p.m. LVN "A" said Resident #2 had first begun complaining of pain during urination on 8/14/12, adding a UA sample had been obtained on 8/15/12, with results obtained on 8/16/12. LVN "A" said there had been no follow-up by nurses, adding it was on her "to do" list following the interview with surveyor. LVN "A" said she was unsure whether or not the DON had been made aware Resident #2 had not yet been administered ABT. LVN "A" acknowedged she had just received additional training within the previous twenty-four hours, that nurses were to report all issues related to not acquiring residents' medications to the DON. LVN "A" acknowledged she had failed to notify the DON regarding Resident #2 having not yet begun ABT. LVN "A" said "I'm sorry, I don't know why I did not tell her (DON)". During an interview on 8/19/12 at 6:20 p.m., the DON acknowledged she had not been aware Resident #2 had received no ABT since his 8/16/12 lab results indicated a bacterial infection. The DON said "I'll take care of it". During a subsequent interview on 8/21/12 at 10:30 a.m., the DON said it was standard practice that ABTs were initiated within four hours of obtaining ABT orders, which were to be obtained immediatly following receipt of lab results. The DON said she was not aware of any orders for Resident #2 to begin ABT following the 8/16/12 lab results until after the facility had been made aware by the state surveyor on the evenong of 8/19/12. The DON acknowledged the recent nurse in-service regarding pharmacy services had been ineffective, as LVN "A" failed to report Resident #2 had not received ABT following his positive UA. During a subsequent interview at 6:25 p.m., the ADM said he was unaware Resident #2 had not begun ABT following positive UA results on 8/16/12. Additionally, the ADM said he had not been aware that all residents' #1 through #16, medications had not been ordered in a timely manner. Review of the Resident Work List provided by the facility on 8/19/12 documented 63 residents.