Every finding on record at Green Hills Center for Rehabilitation and Healing

Based on facility policy review, medical record review, and interview, the facility failed to reimburse funds within 30 days to 2 of 2 (Resident #135 and #136) sampled residents reviewed for personal fund accounts. The findings include: 1. Review of the undated policy titled, Conveyance Resident Funds, revealed .Any funds on deposit with the facility are refunded to the resident, resident representative, or to the resident's estate upon discharge, eviction or death, as applicable.The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative, or to the resident's estate.as applicable within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death. 2. Review of the medical record revealed Resident #135 was admitted to the facility on [DATE], with diagnoses including Acute Kidney Failure, Hypertension, Chronic Kidney Disease, and Atrial Fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #135 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Review of the Progress Note dated [DATE] at 4:38 PM, revealed .new order to send to ER [Emergency Room] . Review of the Progress Note dated [DATE] at 5:02 PM, revealed .resident departed facility via EMS [Emergency Medical Service] . Review of the medical record revealed Resident #135 did not return to the facility following discharge to the hospital. Review of Resident #135's Resident Trust Fund Account revealed, a cleared check issued for the account balance of $1,318.59 was dated [DATE],14 days past the allotted 30 day time period. 3. Review of the medical record revealed Resident #136 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Dependence on Supplemental Oxygen, Hypertension, and Shortness of Breath. Review of the quarterly MDS assessment dated [DATE], revealed Resident #136 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Progress Note dated [DATE] at 11:00 AM, revealed .Instructed to transfer to ER . Review of the Progress Note dated [DATE] at 11:58 AM, revealed .Resident sent out to hospital per Np [Nurse Practitioner] request . Review of the Progress Note dated [DATE] at 6:26 PM, revealed .Called hospital to check on resident. Resident has been admitted to ICU [Intensive Care Unit] . Review of the medical record revealed Resident #136 did not return to the facility following discharge to the hospital. Review of Resident #136's Resident Trust Fund Account revealed, a cleared check issued for the account balance of $7,496.62 was dated [DATE], 16 days past the allotted 30 day time period. During an interview on [DATE] at 5:00 PM, the Business Office Manager (BOM) was shown a copy of Resident #135 and Resident #136's refund checks. The BOM stated, They [the refund checks] are supposed to be sent within 30 days. They [Resident #135 and Resident #136] both passed away in the hospital and unfortunately, we did not know in time to send it [the refund checks] in time. The BOM was asked if both checks should have been sent within 30 days. The BOM stated, Yes. During an interview on [DATE] at 5:25 PM, the Administrator confirmed that Resident #135 and Resident #136 expired in the hospital. The Administrator was asked if the refund checks should have been sent within 30 days. The Administrator stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure food was properly stored, prepared, and served under sanitary conditions, when the facility failed to ensure kitchen equipment was clean and sanitary, when food was stored opened, undated, and expired, when staff failed to cover hair, failed to perform hand hygiene, when food was left uncovered and unattended, and when the ice machine had pink and black build up. The facility served 119 meal trays. The findings include: 1. Review of the facility's undated policy titled, Food and Sanitation, revealed .All local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department .Hair restraints are required and should cover all hair on the head .Beard nets are required when facial hair is visible .All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way .Foods are protected from contamination (dust, flies, rodents, and other vermin) .Foods with expiration dates are used prior to the use by date on the package . Review of the facility's undated policy titled, Food Storage, revealed .Sufficient storage facilities are provided to keep food safe, wholesome and appetizing. Food is stored in an area that is clean, dry, and free from contaminations .Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled with a date before being refrigerated. Leftover food is used within 3 days or discarded .Refrigerated Food Storage .All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be used by their safe use by dates, or frozen .or discarded .Frozen Foods . All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be used by their safe use by dates or discarded . Review of the facility's undated policy titled, Cleaning Instructions: Ovens, revealed .Ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). Spills and food particles will be removed after each use .Remove spills and food particles after each oven use as needed (before re-heating the oven) . Review of the facility's undated policy titled, Cleaning Instructions: Ranges/Griddles, revealed .The range/griddle will be cleaned after and prior to each use. Spills and food particles will be wiped up as they occur .Scrape burned particles and grease off using proper cleaning items (a non-metal scouring pad may be needed for metal surfaces). Wipe the surface with a clean cloth soaked in soapy water .Spills should be cleaned up as they occur . Review of the facility's undated policy titled, Cleaning Instructions, revealed .Bin ice machine and equipment .will be cleaned and sanitized on a regular basis .Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. Pay close attention to the crevices with maintenance assistance .Sanitize . Review of the facility's policy titled, Handwashing Hand Hygiene, dated [DATE], revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Hand hygiene is indicated .after contact with contaminated surfaces .immediately after removing gloves .The use of gloves does not replace hand washing/hand hygiene .Applying and Removing Gloves .Perform hand hygiene before applying gloves . 2. Observation in the kitchen on [DATE] at 11:31AM, revealed the following: a. thick black buildup of an unknown substance on top of the cooking stove and the 2 eyes on the cooking stove. b. [NAME] W, [NAME] V with no facial hair covering. c. Black grease with brown crumbs in the deep fryer. d. A tomato, a bag of cheese, a bag of purple cabbage, a bag of carrots, sliced turkey in a clear package, and a bag of lettuce, on a metal prep table, opened and undated. e. Dark brown and black build up on the griddle. 3. Observation of the kitchen dry storage room on [DATE] at 11:56 AM, revealed 12 cans of Ravioles De Carne De Res on a metal shelf, dated best if used by [DATE]. 4. Observation in the kitchen on [DATE] at 12:10 PM, revealed the following: a. Dietary Aide X had no facial hair covering. b. Dietary Aide Y had no hairnet on. c. Dietary Aide Z failed to perform hand hygiene before putting on gloves to prepare food. 5. Observation in the kitchen in the freezer on [DATE] at 12:15 PM, revealed the following: a. 3 plastic bags of meat unlabeled, undated b. A bag of okra, undated. c. A bag of vegetables, opened, unsealed and undated. d. A bag of cookie dough, opened, unsealed, and undated. e. A bag of cheese pizza opened, unsealed and undated. h. 12 bags chopped turnip greens, undated. i. A bag of broccoli, undated. 6. Observation in the kitchen on [DATE] at 10:09 AM, revealed a. Chef DD had no facial hair covering. b. Dietary Aide AA failed to properly perform hand hygiene before food preparation. c. Dietary Aide CC had no facial hair covering and had no hairnet on. d. A thick black buildup of an unknown substance on top of the cooking stove and the 2 eyes on the cooking stove. e. [NAME] V had no facial hair covering. f. A black buildup of an unknown substance inside the ovens and brown buildup of an unknown substance on the inside of the ovens' doors. 7. Observation in the kitchen in the walk-in cooler on [DATE] at 10:23 AM, revealed the following: a. 3 containers of Cottage Cheeses dated use by [DATE]. b. 11 packages of turkey bacon slices, opened and undated. c. An unidentified meat, opened, undated, unlabeled. 8. Observations in the kitchen on [DATE] at 11:25 AM, revealed [NAME] V used his gloved hands to scoop an identified liquid off the floor, removed his gloves, and failed to perform hand hygiene before putting on another pair of gloves. There was a pan of noodles and a pan of meat, uncovered and unattended, on a rolling cart and [NAME] V, Chef DD, and Dietary Aide CC had no facial hair covering. 9. Observations in the kitchen on [DATE] at 12:04 PM, revealed [NAME] V on the food line and failed to have a facial hair and hair covering. [NAME] V removed his gloves, began to take the tray line food temperature without performing hand hygiene and without wearing gloves. 10. Observations and interview in the kitchen on [DATE] at 1:53 PM, revealed the plastic white flap inside the ice machine had 2 rusted screws, a cluster of small black dots centered in the middle of the flap, and an unknown pink substance on the lower right edge of the flap, black build up on the 2 grooves of the plastic flap where the plastic flap and the metal of the ice machine meet, and the upper corners of rubber trim inside of the lid. The Regional Food and Nutrition Director confirmed there should be no rusted screws, no black build up, and no pink substance inside of the ice machine. During an observation and interview in the kitchen on [DATE] at 3:31 PM, the Maintenance Director was shown the ice machine and confirmed the black substance was mold. 11. Observations in the kitchen in the food prep area on [DATE] at 4:13 PM, revealed an unattended and uncovered pan of cooked meat, cooked bacon, baked apples, and instant potatoes. During an observation and interview on [DATE] at 4:20 PM, the Regional Food and Nutrition Director confirmed food should be covered when left unattended, confirmed the thick black build up on top of cooking stove and the 2 eyes needed to be removed, confirmed the black build up inside the ovens and the brown build up on the inside of the ovens' doors needed to be removed, and confirmed the griddle needed to be cleaned to remove the dark brown and black build up. 12. Observations in the kitchen dishwashing room on [DATE] at 9:19 AM, revealed Assistant Dietary Manager BB failed to perform hand hygiene before applying gloves and placed clean dishes on a soiled rolling cart. During an interview on [DATE] at 4:54 PM, the Regional Food and Nutrition Director confirmed facial hair and hair should be covered with a net, confirmed dietary staff should perform hand hygiene whenever entering the kitchen, whenever removing gloves and before donning clean gloves, and confirmed carts should be cleaned before placing clean dishes on them.

Based on policy review, medical record, observation, and interview, the facility failed to provide care and services for the prevention of pressure ulcer/injury for 1 of 4 (Resident #61) sampled residents reviewed for pressure ulcer/injuries. The findings included: 1. Review of the facility's policy titled, Pressure Injuries Overview, dated 1/28/2025, revealed .Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence .A pressure injury will present as intact skin and may be painful .A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful .Pressure ulcers/injuries occur as a result of intense and prolonged pressure .The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue .Tissue tolerance is the ability of the skin and its supporting structures to endure the effects of pressure, without adverse effects. Tissue tolerance affects the length of time a resident can maintain a position without suffering a pressure ulcer/injury .Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer .Slough and/or eschar may be visible .Depth varies by anatomical location .If slough or eschar obscures the extent of tissue loss, this is an Unstageable PI .Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon discoloration or epidermal separation reveals a dark wound bed or blood-filled blister .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated 11/30/2022, revealed .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s) .the nurse shall describe and document/report the following .Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue .Pain assessment .Resident's mobility status .Current treatments, including support surfaces .and all active diagnoses . Review of the facility's policy titled, Pressure Ulcer Risk Assessment, dated 9/2013, revealed .The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers .Review the resident's care plan to assess for any special needs of the resident .Review current Braden Scale or facility risk assessment tool .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissue .If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected .Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin .perspiration, wound discharge .Encourage the resident to participate in active and passive range of motion exercises to improve circulation .Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor .Skin Assessment .skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .Staff will perform routine skin inspections (with daily care) .Nurses are notified to inspect the skin if skin changes are identified .Nurses will conduct skin assessments at least weekly to identify changes .Extrinsic risk factors for pressure ulcers include .pressure .the resident is not capable of moving without assistance, is confined to bed, and/or requires a regular schedule of turning .Steps in the procedure .Once inspection of skin is completed proceed to the Weekly Skin Integrity tool and complete documentation of findings .If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin .Proceed to care planning and interventions individualized for the resident and their risk factors .The following information should be recorded in the resident's medical record utilizing facility forms: The type of assessment conducted .( .Weekly Skin Integrity tool) The date and time and type of skin care provided .The name and title( or initials) of the individual who conducted the assessment .The condition of the resident's skin ( .the size and location of any red or tender areas) .If resident refused the treatment, the reason for refusal the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal .Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted .Documentation in medical record addressing MD notification if new skin alteration noted with a change of care plan .Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care . 2. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis, Chronic Pain, and Muscle Weakness. Review of Resident #61's Care Plan dated 11/15/2024, revealed .Resident requires assist with activities of daily living .Has left sided neglect [a neurological condition where a person fails to notice, attend to or respond to stimuli on their left side] please be aware .skin inspection .monitor for redness, open areas .immediately report changes to the nurse .Resident prefers two showers per week .At risk for pressure injury development .Resident will be free of pressure injury development .Administer treatments as ordered and monitor for effectiveness .Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during .mobility .and frequent repositioning .Notify nurse immediately of any new areas of skin breakdown .Redness, Blisters, Bruises, discoloration noted during bath or daily care .Remind/assist resident to frequently change position when in bed and/or chair .The resident is resistive to care r/t [related to] Refusing Showers .Allow the resident to make decisions about treatment regime, to provide sense of control .If resident resists with ADL's [activities of daily living skills], reassure resident, leave and return 5-10 minutes later and try again .Provide resident with opportunities for choice during care provision .The resident has Hemiplegia/Hemiparesis r/t history of CVA [cardiovascular accident] .The resident will remain free of complications or discomfort related to Hemiplegia/Hemiparesis through review date .The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis through review date .Range of motion (active or passive) with am/pm care daily .Assist with ADLs/Mobility as needed . Review of Resident #61's Braden Scale dated 11/23/2024, revealed .Score: 12 .Category: High Risk .SENSORY PERCEPTION .Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned .has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities .MOISTURE .Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift .ACTIVITY .Bedfast: confined to bed .MOBILITY .Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent of significant changes independently . Review of Resident's #61's quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #61's had a Brief Interview for Mental Status score of 13, indicating intact cognition and functional ability was coded as dependent for all activities of living. Review of facility's Nosocomial Pressure Ulcer form dated 1/20/2025, for Resident #61 revealed .a suspected DTI [Deep Tissue Injury] to front of left ear .Staff stated resident lays primarily on left side .Resident has decreased bed mobility . This document was presented to state surveyors via email after exit date from facility. The bottom of the document stated, Not part of the Medical Record. The facility failed to provide this documentation when surveyors were in the building from 1/27/2025 to 2/3/2025. Review of Resident #61's medical record did not show documentation of the DTI to the left ear on 1/20/2025. No Physician's Order for treatment to the DTI, no documentation of the appearance or size of the pressure injury, and no documentation for a treatment to the DTI to the left ear on the facility's treatment administration record (TAR). Review of the facility's Skin and Wound Evaluation sheet dated 1/21/2025, revealed .Type .Pressure .stage 4: Full -thickness skin and tissue loss .In-House Acquired .wound present .exact date 1/21/2025 .Wound measurements .Length 1.5 cm[centimeters] .Width 1.0 cm .depth not applicable .Wound bed Granulation 40% [percent] of wound bed .Exudate .Light .serous .Surrounding tissue .Erythema: redness of skin . Review of the Physician's Order dated 1/21/2025, revealed .Pressure stage 4 front left ear .cleanse with NS [normal saline] apply Medi honey [medication used to debride pressure ulcers from stage 1 to stage 4) cover with dry dressing M [Monday] W [Wednesday] F [Friday] and as needed . Review of Resident #61's TAR for January 2025, revealed the TAR was signed out on 1/22/2025. No documentation the treatment was performed until 1/22/2025. Review of the facility's Skin and Wound Evaluation sheet dated 1/24/2025, revealed .Type .Pressure .Stage 4 .In-House Acquired .Exact date 1/21/2025 .Wound Measurements .Length 1.5 cm .Width 0.8 cm .Depth 0.3 cm .Wound bed Granulation 20%of wound filled .slough 40% of wound filled .Exudate none .Surrounding tissue .Normal in color . Observation in Resident #61's room on 1/27/2025 at 11:41 AM, revealed Resident #61 lying in bed on his back with his head turned to the left side and no wound dressing to his left ear pressure ulcer/injury. Observation in Resident #61's room on 1/28/2025 at 9:11 AM, revealed Resident #61 was laying on his left side with no dressing to his left ear pressure ulcer/injury. Review of Resident #61's medical record revealed nutritional interventions were not put in place and started until 1/28/2025, 1/29/2025 and 1/31/2025. Observation in Resident #61's room on 1/30/2025 at 10:10 AM, revealed Resident #61 in bed laying on his left side, stage 4 pressure injury to left ear appears red with open area with serosanguinous drainage, and no intact wound dressing. Review of the facility's INTEGRATED WOUND CARE Follow-up Progress Note dated 1/31/2025, revealed .[Named] Resident [#61] confused and combative .he has weakness and has contracted left elbow .He is unable to turn his head toward the right .has purulent drainage to left ear canal .HOH [hard of hearing] .delayed wound healing .placed on air mattress today .Wound: Pressure ulcer Front Ear left Stage 4 . L [length] x [by] W [width] x D [depth] cm [centimeter] 1.5cm x 0.4 cm x 0.2 cm .EXUDATE: Light Serous .Treatment Recommendations: Medi honey, cover with gauze and Tegaderm .Q [every] D [day]and PRN [as needed] . During an interview on 1/31/2025 at 9:44 AM, the Director of Nursing (DON) was asked when Resident #61's pressure injury stage 4 was observed. DON stated, It was observed on 1/21/2025. The DON was asked if pressure injuries should start at a stage 4. The DON stated, No, not typically, but he tends to lay his head to the left side. The DON was asked what caused the development of the pressure injury to Resident #61's left ear. The DON stated, I feel the pressure injury was caused by his head laying to the left side .I'm sure that didn't help the ear area that he lays on. The DON was asked if a wound dressing should be intact on the ear. The DON stated, Yes. The DON was asked if nutritional interventions were started on 1/21/2025.The DON stated, No, but the Nurse Practitioner will do that today . The DON was asked should the resident have had interventions put into place as soon as the wound was identified. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 3 of 9 (100 Hall Medication Cart #1, 200 Hall Medication Cart #1, and 300 Hall Medication Room) storage areas when external and internal medications were stored together and with toxic chemicals, medications stored opened and undated, and when discontinued medications were stored in the medication room, and when 1 of 9 (300 Hall Medication Cart #2) storage areas was left unsecure, unattended, and out of sight of the nurse The findings include: 1.Review of the facility policy title, Medication Labeling and Storage, dated 5/19/2023, revealed .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .Compartments (including .drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others .Antiseptics, disinfectants, and germicides used in any aspect of resident care .shall be stored separately from regular medications . Review of the facility's policy titled Administering Medications, revised April 2019, revealed .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .The cart must be clearly visible to the personnel administering medications . 2. Observation and interview on the 200 hall Medication Cart #1 on 1/30/2025 at 12:07 PM, revealed the following: a. 1 plastic container of (Named) Disinfectant wipes stored with heparin (blood thinner) 5ml (milliliter) lock flushes in the bottom drawer of the medication cart without a separation barrier. b. 1 box of [NAME] Pain Relief Gel Packets opened and undated c. oral medications of Azathioprine (medication used for rheumatoid arthritis) 50mg (milligram) tablets, Duloxetine (medication used for depression) 60mg capsules, Folic Acid (dietary supplement) 10mg tablets, Gemtesa (medication used for overactive bladder) 75mg tablets, cetirizine (allergy medication) 10mg tablets, methotrexate (medication used to treat cancer) 2.5mg tablets, stored in a plastic container without a barrier with the following medications used for skin irritation: An 8oz (ounces) bottle of 12% (percentage) ammonium lactate lotion (to treat dry, itchy, and scaly skin). A 2oz tube of 20% Zinc Oxide ointment A 4oz tube of calmoseptine ointment (protects and helps heal skin irritations). A 15 gram bottle of Nyamyc (to treat cutaneous and mucocutaneous infections). During an interview with Licensed Practical (LPN R), LPN R confirmed that internal medications should not be stored with external medications, and that toxic chemicals should not be stored with external or internal medications. 3. Observation on the 100 Hall Medication Cart #1 on 1/30/2025 at 12:30 PM, revealed the following: a. A box of scopolamine transdermal patches (to prevent motion sickness and used in surgery) stored in a compartment without a barrier, with 2 Lantus Insulin injection pens and a vial of Ondansetron 4mg injection. b. A 32oz bottle of Critical Care LPS Liquid Protein oral supplement opened and undated. c. A bottle of SDS 15 gram oral suspension (used to treat yeast in the mouth) stored in a compartment with 2 bottles of Fluticasone (to relieve symptoms of rhinitis (stuffy nose)) 50mcg (microgram) nasal spray, 1oz bottle of nasal decongestant spray, 1oz (Named) nasal spray, 1.5oz bottle of deep sea nasal saline spray. During an interview on 1/30/2025 at 12:30 PM, Registered Nurse (RN HH) confirmed that internal and external medications should be stored separately and not with toxic chemicals. RN HH confirmed that all medications should be labeled with an opened date. RN HH confirmed that if medications are stored in the same compartment, they should have a divider to separate them, and that oral medications, ointments, and injections should not be stored with nasal medications. 4. Observation on 1/31/2025 at 8:32 AM, revealed LPN O went into Resident #106's room to administer medications and left the 300 Hall Medication Cart #2 unsecured, unlocked, and out of sight. During an interview on 2/3/2025 at 8:55 PM, the DON was asked should the medication cart be left unlocked and out of sight of the nurse. The DON stated, No. 5. Observation and interview in the 300 Hall Medication Room on 2/3/2025 at 11:47 AM, revealed 2.5% Hydrocortisone Cream (treats skin conditions) stored in the medication room cabinet, ordered for Resident #47. LPN Q confirmed the medication was discontinued and the resident no longer receives the medication. LPN Q confirmed that the medication should be sent back to pharmacy or discarded when it is discontinued and should not be stored in the cabinet. 49269

Based on review of the Resident Rights document, medical record review, observation, and interview, the facility failed to treat residents with respect and dignity when 4 of 15 (Certified Nursing Assistant (CNA) K, L, M, N) and (Minimum Data set (MDS Nurse) staff members stood over a residents (Resident #12, #33, #45, #54, and #90) to assist with the meal. The findings include: 1. Review of the facility's Resident Rights, document dated February 2021, revealed .Employees shall treat all residents with kindness, respect, and dignity . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Resident #12 required assistance from staff for eating, bathing, grooming, and dressing. Observation on 1/28/2025 at 7:45 AM, revealed CNA K stood over Resident #12 to assist her with the meal. 3. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Insomnia, Anxiety, and Pain. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 00, which indicated Resident #33 had severe cognitive impairment. Resident #33 required assistance from staff for activities of daily living (ADLs). Observation on 1/28/2025 at 8:01 AM, revealed CNA M stood over Resident #33 to assist her with the meal. 4. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Adult Failure to Thrive, Cerebrovascular Disease, and Bell's Palsy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #45 was cognitively intact. Observation on 1/28/2025 at 8:01 AM, revealed CNA L stood over Resident #45 to assist her with the meal. 5.Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Diabetes, Contractures, Chronic Obstructive Pulmonary Disease, and Anxiety. Review of the annual MDS assessment dated [DATE] revealed Resident #54 had a BIMS score of 15. Resident #54 was dependent on staff for eating, bathing, grooming. Observation on 1/27/2025 at 12:27 PM and on 1/28/2025 at 7:57 AM, revealed CNA K stood over Resident #54 to assist him with the meal. Observation on 1/31/2025 at 8:29 AM, revealed MDS Nurse stood over Resident #54 to assist him with the meal. 6. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Diabetes, Lymphedema, Glaucoma, Heart Failure, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #90 was cognitively intact. Resident was dependent on staff for eating, toileting, bathing, transfers. Observation on 1/28/2025 at 8:15 AM, revealed CNA N stood over Resident #90 to assist him with the meal. 7. During an interview on 2/3/2025 at 8:55 PM, the Director of Nursing (DON) was asked should staff stand over a resident to assist with their meal. The DON stated, No, should sit at bedside. Should not stand over them. 49269

Based on policy review, observation, and interview, the facility failed to maintain privacy and confidentiality of residents' medical record for 27 of 119 (Resident #4, #10, #11, #19, #23, #27, #29, #31, #33, #36, #41, #47, #50, #51, #52, #53, #60, #75, #77, #81, #82, #88, #94, #98, #106, #107, and #110) sampled residents observed during a random observation and medication administration. The findings include: 1. Review of the facility's policy titled, Resident Rights, dated 2/2011, revealed .Employees shall treat all resident with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .privacy and confidentiality . 2. Observation on the 200 Hall on 1/30/25 at 12:07 PM, revealed Licensed Practical Nurse (LPN R) sitting at the nurses' desk away from the 200 Hall Medication Cart #1. During observation and interview at the 200 Hall Medication Cart #1 on 1/30/2025 at 12:08 PM, revealed the computer screen opened and viewable with the following residents name and room numbers visible: Resident #4, #29, #31, #36, #41, #50, #51, #60, #75, #81, #82, #98, #107, and #110. LPN R was asked should the computer screen be left opened, unattended with residents' information visible and viewable. LPN R stated, No, it should be closed when no one is at the cart . 3. Observation on the 300 Hall at Medication Cart #2 on 2/3/2025 at 4:09 PM and 4:11 PM, revealed the computer screen left opened and viewable with the following residents name and room numbers visible: Resident #10, #11, #19, #23, #27, #33, #47, #52, #53, #77, #88, #94, and #106. LPN Q left the computer screen opened and unattended when she entered Resident #94's room and when she entered Resident #53's room leaving the computer screen up and visible with the residents' name and room numbers displayed on the screen. 4. During an interview on 2/3/2025 at 8:55 PM, the Director of Nursing (DON) was asked should the computer screen be left unattended with residents' name and room numbers displayed. The DON stated, No .

Based on policy review, medical record review, and interview, the facility failed to conduct quarterly care conference meetings for 5 of 24 (Resident #9, #10, #25, #36, and #39) sampled residents reviewed. The findings include: 1.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, revealed .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan or care, including the right to .participate in the planning process .identify individuals or roles to be included .request meetings .request revisions to the plan of care .participate in establishing the expected goals and outcomes of care .participate in determining the type, amount, frequency and duration of care .see the care plan and sign it after significant changes are made .The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Stroke, Hypertension, Malnutrition, and Asthma. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #9 had mild cognitive impairment. Review of the medical record revealed the facility held a care plan meeting on 6/17/2024. The facility failed to provide documentation of quarterly care plan meetings for Resident #9 since 6/17/2024. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Cancer, Hypertension, Anemia, Diabetes, and CVA. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 14, which indicated Resident #10 had no cognitive impairment. Review of the medical record revealed the last care plan meeting was 3/22/2024. The facility failed to provide documentation of quarterly care plan meetings for Resident #10 since 3/22/2024. 4. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Polymyositis, Obstructive Sleep Apnea, Neuromuscular Dysfunction of Bladder, and Depression. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated Resident #25 had no cognitive impairment. Review of the medical record revealed a care plan meeting was held with Resident #25 on 6/3/2024. The facility was unable to provide documentation of the next scheduled care plan meeting for Resident #25 until 2/3/2025. 5. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Chronic Pain, Diabetes, Myelopathy, Chronic Obstructive Pulmonary Disease, and Paraplegia. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 had no cognitive impairment. Review of the medical record revealed a care plan meeting was held with Resident #36 on 7/11/2024 and the next care plan meeting was not provided until 12/11/2024. The facility failed to provide documentation of quarterly care plan meetings for Resident #36. 7.Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. Review of the significant change MDS dated [DATE], revealed a BIMS score of 14, which indicated Resident #39 was cognitively intact. Review of the Care Conference Notes revealed the facility held a care plan meeting on 4/4/2024 and 6/20/2024. The facility failed to provide documentation of quarterly care plan meetings for Resident #39 since 6/20/2024. 8. During an interview on 2/3/2025 at 8:04 PM, the Director of Nursing (DON) confirmed that care plan meetings should be held quarterly. 47835 49269

Based on policy review, medical record review, and interview, the facility failed to ensure a safe and secure environment for 1 of 1 (Residents #25) residents reviewed for accident hazards. The findings include: 1. Review of the facility's undated form titled .AGAINST MEDICAL ADVICE-ACKNOWLEDGEMENT AND WAIVER . revealed .The above named physician has recommended a specific course of therapy, method of treatment or a means diagnosing and/or treating a medical condition for the patient named .is a medical decision that is made by the physician based upon the findings of an examination and/or diagnostic testing .The physician believes this recommendation is in the patient's best interest .The specific recommendation(s) being made by the physician includes the following [blank lines to include the physician's recommendations] .The patient has elected not to follow the recommendations of the physician as noted above and accepts responsibility for any consequences of that decision .The risks of not following the physician's recommendations have been fully explained to the resident by the physician .The patient agrees that the physician shall not be held responsible or legally liable for the decision or any future consequences of the patient's decision .By signing .the patient acknowledges that s/he has read this information and has elected not to follow the physician's recommendations . 2. Review of the facility policy titled, SUBSTANCE USE DISORDER, dated 11/2022 revealed, .Residents who are admitted to the facility with substance use disorder (SUD) will receive the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being, provided by the facility and in accordance with the comprehensive assessment and care plan .SUD is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment .The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record .In addition, safety and health concerns specific to the resident and his or her history are identified .Health and safety considerations related to substance use disorder may include .increased risk of falls and other accidents .potential for wandering and elopement .potential for resident-to-resident altercations and other disruptive behaviors .potential for .mood disorders .Care plan interventions are directed at maintaining the safety of the resident, staff and other residents .examples of appropriate care interventions .include .monitoring the resident for .changes in behavior .slurred speech .lack of coordination .especially after returning from a leave of absence .increasing supervision of the resident .Behavioral contracts may be initiated to address behaviors .used .with residents who have the capacity to understand them communicates the resident's rights to have a leave of absence and also explains the health and safety risks of leaving without facility knowledge or leaving against medical advice (AMA) .if substance abuse is suspected, a behavioral contract may stipulate .monitoring and supervision .may be increased .voluntary inspections may be conducted if there is reasonable suspicion of .unauthorized items .local law enforcement will be notified if there is suspicion .of illegal substances .Non-adherence to the contract will be treated as a care plan intervention that needs attention or needs to be altered to meet the needs of the resident .The IDT [Interdisciplinary Team] will work with the resident .to revise the care plan and contract . 3. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Polymyositis, Neuromuscular Dysfunction of Bladder, and Depression. Review of the admission Minimum Data Set (MDS) dated [DATE], and the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment, required maximum assistance with transfers, and the use of a motorized electric wheelchair. Review of a Progress Note dated 6/8/2024, revealed . resident yelling out help call 911 .consumed delta 8 [tetrahydrocannabinol-THC-the main psychoactive substance found in the Cannabis plant] gummies bought outside of facility. took gummies and locked in cart. Np [nurse practitioner] advised to check vitals q [every]15 (minutes) for hr [hour] .resident back in bed, will continue to monitor . The facility was unable to provide documentation that Resident #25 was monitored and assessed for the effects of the consumption of a Cannabis gummy every 15 minutes for an hour as ordered by the nurse practitioner. Review of the Care Plan dated 6/21/2024 revealed .Substance Abuse Disorder (history of polysubstance abuse .Resident has dx [diagnosis] of history substance abuse disorder cocaine and ETOH [alcohol] with potential for negative outcome .Resident is at risk for substance use/abuse, self medications, including over medicating, drug seeking behaviors .Delta 8 Gummy (candy with marijuana) Use .observe for s/s [signs and symptoms] for sue [SUD] or self medicating including over use (drowsiness, changes in mental status, behavior changes, notify provider of acute changes .) Review of the Encounter Note dated 7/8/2024, revealed .resident has left facility on multiple occasions and returned intoxicated from alcohol [from alcohol] or delta 8 .Reports that she goes to a Mexican restaurant every Friday and has a few margaritas . Review of the Nursing Progress Note dated 7/31/2024, revealed .Resident .asked if therapy could take her off campus via [by way of] the driveway .facility staff could not because there is no safe egress to the street from center property . Review of the Nursing Progress Note dated 8/4/2024, revealed .Followed resident off property due to safety concerns, ignoring traffic signals and riding down the middle of the driveway. The facility was unable to provide documentation what time Resident #25 returned back to the facility after leaving AMA, and documentation of the education given on the importance of following traffic signals and the risk of riding in the middle of the driveway. Review of the Nursing Progress Note dated 8/4/2024, revealed .signed out on LOA, returned to facility with (3) 375 ml [milliliters] of Vodka [clear alcoholic beverage) .Resident stated she was going to go hide them on property so she can take it with her on Wed [Wednesday] for LOA . Review of the Encounter Note dated 8/5/2024 revealed .The facility has one entrance, which is a sloped driveway directly connected to a main street. Staff reports that resident will ride her motorized wheelchair down the driveway, which poses a concern for entering the street. While out recently, resident purchased 3 bottles of liquor and brought them back to the facility. When facility staff stopped her, resident reported that she brought them to drink when she takes a leave of absence in the next few days . Review of the Nurse Practitioner Note on 8/5/2024, revealed .The patient was observed exiting the property via her motorized wheelchair, navigating the car entrance and exit ramp and heading towards a busy street on 8/4/24. This behavior was deemed unsafe and against facility protocols previously .Additionally, nursing staff confirms her purchasing three pints of [NAME] Vodka during her outing and bringing them back [them back] into the facility, which raises safety concerns regarding alcohol use in conjunction with operating her motorized wheelchair . Alcohol use . Review of the Care Plan updated and revised on 8/5/2024 revealed .Resident fails to comply with LOA [Leave of Absence] policy, despite education .Encourage resident to be safe while in the community on LOA ( .utilize cross walks, no panhandling, no drugs or ETOH use .) .Explain possible adverse reaction related to unsafe behavior while in community . Review of the Nurse Practitioner Note on 8/12/2024, revealed .found outside expressing extreme distress and confusion .behavior has been erratic .today .was found in possession of alcohol, directly contravening facility rules .safety concerns after a discussion with a police officer .gave .bottle of Fireball to the police officer .The patient has violated the facility's alcohol policies at least twice, including an instance today when she was found with a bottle of Fireball . Review of the Encounter Note dated 8/26/2024 revealed .Staff reports that on 8/12 [2024], resident was found outside of the facility inebriated and with alcohol on her person .proceeded to make accusatory and paranoid statements, saying .staff was holding her hostage .would not let her leave .police were called and the alcohol .was confiscated. Resident [#25] was returned to her room and placed on every 15-minute rounds for safety and behavioral management .extensive history of leaving the facility to obtain alcohol and illicit substances .has been told it is unsafe .to leave the facility independently .due to her physical limitations and usage of a motorized wheelchair . The facility was unable to provide documentation of the 15 minute checks for Resident #25 after leaving the facility AMA and returning with alcoholic beverages and being inebriated. Review of the facility's Against Medical Advice forms, revealed the facility failed to ensure the completion of the AMA forms for 11/11/2024, 11/12/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/23/2024, 11/25/2024, 11/27/2024, 12/7/2024, 12/11/2024,12/13/2024, 12/15/2024, 12/17/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024, 1/1/2025, 1/4/2025, 1/8/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/14/2025, 1/15/2025, 1/17/2025, 1/19/2025, 1/23/2025, 1/25/2025, 1/28/2025, 1/29/2025, 2/1/2025, and 2/3/2025, to include what education was given to Resident #25 when she signed the AMA form to leave the facility on LOA. There was no documentation of the times when Resident #25 left the facility AMA and when she returned to the facility, and no documentation of a Resident assessment and monitoring done upon return to the facility. During an interview on 1/28/2025 at 2:15 PM, Resident #25 stated they say cars come in too fast .I like to go get a drink every once in a while, will go to [restaurant] or liquor store .I've downed my drinking to just fairly tipsy then just coming back and watch a movie . During an interview on 1/30/25 at 11:52 AM, the Administrator presented a form called Against Medical Advice-Acknowledgment and Waiver and stated, .This is for the ones who want to leave and go do their thing because they have a BIMS of 15 .who want to go out and drink or that goes out in the dead of winter .they have to sign that before they can go out . During an interview on 2/3/2025 at 10:17 AM, the Administrator stated .If she [Resident #25] is belligerent or yelling out we will assume she has been drinking .We had to ask one of her friends one time to meet her in the lobby to visit because she was seen bringing stuff [alcohol] in for her . During an interview on 2/03/2025 at 10:48 AM, Receptionist FF stated .We will ask her where she is going, sometimes she will tell us, sometimes not .If she won't tell us where she's going, we will make her sign the AMA paper . Sometimes she will say she is going just out there to sit but will go somewhere else .If I notice she is gone, I will let the administrator know. She [Resident #25] goes out multiple times throughout the day . During an interview on 2/3/2025 at 11:36 AM, LPN EE stated .she is supposed to sign out when she goes out .will call administrator if I suspect she is intoxicated .I will just get her vital signs .Last Friday she had a tech she got mad at, flipped out on her .come to find out she had been out drinking .If I notice she is not on the floor for a couple hours or something I will usually call down to the front desk to see if she has checked out or something .but no she doesn't come tell me if she is going out or not . During an interview on 2/3/25 at 12:05 PM, the Administrator stated .The only thing that she signs out on is the AMA and LOA forms .AMA when she is going outside or somewhere on her own, the LOA when she is leaving with family or to the doctor. No, she doesn't put the times down .we just have the date she is leaving and the date she is coming back .If we look outside and she is gone they will call me .I text her or call her .she's usually within a block of this place .unless she takes the bus and goes somewhere else. If she comes back and we think she is intoxicated, I will call the police. I did call them one time but by the time they got here she was already in the building. They told me they couldn't do anything if she is in here. During an interview on 2/3/2025 at 9:32 PM, the Administrator was asked what system was in place to ensure the safety of Resident #25 while she is out AMA. The Administrator was unable to say what was put in place other than the AMA form. The Administrator was asked if there was documentation of the education given each time when Resident #25 goes out AMA. The Administrator was unable to provide documentation of the education that Resident #25 was given related to her leaving the facility AMA, traffic and safety issues, and her returning back to the facility intoxicated other than the incomplete AMA forms provided. The Administrator was asked if the AMA sheet was completely filled out if it was missing the responsible Physician, times, and a witness signature. The Administrator stated, . That's just the sheet that we made up to remind her she is going out against medical advice . The Administrator confirmed that the facility was responsible for the safety of Resident #25 and that a plan needed to be in place to ensure the safety of Resident #25 and other residents. 49269

Based on the Center for Disease Control (CDC) guidelines, policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 2 staff members (Certified Nurse Assistant (CNA S) and Licensed Practical Nurse (LPN O) failed to properly store soiled linens, and wear Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP), and failed to properly disinfect reusable medical equipment. The findings include: 1. Review of the CDC guidelines dated 6/28/2024, revealed .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multi-Drug Resistant Organism] . 2. Review of the facility's policy titled, Cleaning Guidelines for the Prevention of Covid-19, dated 3/29/2022, revealed .Compliance with Infection Prevention .Use proper hand hygiene and PPE at all times . Increase the cleaning and disinfecting of high-touch items and surfaces in the following areas . Clinical Care Equipment . General Shared Equipment . 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Hypertension, Heart Failure, and Absence of Right Toe. Review of the admission [NAME] Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #7 had intact cognition. Review of the Physician's Order dated 11/19/2024, confirmed Resident #7 had an order for Enhanced Barrier Precautions related to a wound on the right foot. A random observation in Resident #7's room and interview on 1/27/2025 at 12:46 PM, revealed soiled linen lying on the floor of Resident's #7's room. CNA S confirmed she placed the soiled linen on the floor. 4. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Guillain Barre Syndrome, Hypertension, Diabetes, Hemiplegia, Anxiety, and Asthma. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated Resident #77 was cognitively intact and had a Stage 4 pressure wound. During an observation and interview on 1/27/2025 at 4:23 PM, revealed LPN O was asked to come to Resident #77's room and was asked if soiled linen should be left in the resident's floor. LPN O confirmed soiled linen should not be left in the floor in residents' room. LPN O kicked the soiled linen with his foot behind the resident door and exited Resident #77's room. During an observation on 1/27/2025 at 4:27 PM, LPN O donned gloves and removed the soiled linens from Resident #77's floor and failed to don PPE for EBP. 5. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Human Immunodeficiency Virus [HIV] Disease, Atrial Fibrillation, and Aphasia. Observation on 1/31/2025 at 8:39 AM, revealed LPN O went in to Resident #106's room and placed the blood pressure machine on the left wrist and the pulse oximeter on the resident's finger. LPN O placed the blood pressure cuff and pulse oximeter into the top pocket of his scrub shirt once he obtained the results. LPN O exited the room and returned to the medication cart, placed the blood pressure cuff and the pulse oximeter into the medication cart drawer, and failed to clean or disinfect the reusable equipment. During an interview on 2/3/2025 at 8:04 PM, the Director of Nursing (DON), confirmed that soiled linens should not be left on the resident's floor, and staff should wear a gown and gloves in a resident's room who is in EBP. During an interview on 2/3/2025 at 8:53 PM, the DON confirmed reusable resident equipment should be disinfected after use. 46047

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services related to activities of daily living (ADLs) for 3 of 7 (Resident #5, #9, and #317) sampled residents for ADLs. The findings include: 1. Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with .hygiene (bathing, dressing, grooming, and oral care) . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment .resident required assistance for all ADLs. Review of the Care Plan dated 5/9/2024, revealed .Resident requires assist with activities of daily living .Assist with bed mobility, transfers, toileting, and bathing as required . Review of the Skin Monitoring: Comprehensive CNA [Certified Nursing Assistant] Shower Review, dated 1/3/2025 revealed the facility failed to complete the sheet except for signature. Review of the facility's Skin Monitoring: Comprehensive CNA Shower Review, for January 2025 revealed Resident #5 did not receive a shower after 1/7/2025. The facility was unable to provide documentation Resident #5 received a shower or bath after 1/7/2025 for the month of January 2025. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Stroke, Hypertension, Malnutrition, and Asthma. Review of the annual MDS assessment dated [DATE], revealed BIMS score of 10, which indicated moderate cognitive impairment. Resident #9 required maximal assistance with bathing and showers. Review of the facility Podiatry Referrals form for the 300 Hall revealed 8-18 [2024] .[Named Resident #9] Review of Physician's Order dated 1/11/2023, revealed May receive services from .Podiatrist .and other specialist(s) as necessary. Review of the Nurses Note dated 8/18/2024, revealed [Named Daughter] stated, .give him a shower, and cut his toenails . Observation in Resident #9's on 1/28/2025 at 1:41 PM, revealed CNA II removed Resident #9's socks to assess his feet. The toenails were long, thick, and unkempt. During an observation and interview on 1/31/2025 at 11:50 AM, Unit Manager 3rd was shown Resident #9's fingernails and toenails and confirmed the resident needed to be seen by podiatry. 4. Review of the medical record revealed Resident #317 was admitted to the facility on [DATE], with diagnoses including Cerebral Vascular Accident, Dysphagia, and Percutaneous Endoscopy Gastrostomy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated Resident #317 had severe cognitive impairment, and was dependent upon staff for ADLs. Review of the Care Plan dated 1/17/2025, revealed Resident #317 was dependent upon staff for showers and grooming. Review of the Master Shower Schedule sheet revealed Resident #317 was scheduled for showers on Tuesdays and Fridays. Review of the facility's electronic Shower Sheet revealed Resident #317 had not received a shower since 1/17/2025. Observations in Resident #317's room on 1/28/2025 at 8:30 AM and 2:40 PM, on 1/30/2025 at 8:02 AM and 5:05 PM, on 1/31/2025 at 7:51 AM and 1/31/2025 at 1:06 PM, and on 2/3/2025 at 10:35 AM, revealed Resident #317's hair was unkept and uncombed. During an interview on 2/3/2025 at 10:44 AM, Licensed Practical Nurse (LPN U) confirmed residents should get a shower two times per week, and CNAs should complete shower sheets. LPN U confirmed Resident #317 had not had a shower since 1/17/2025 and the resident should have received showers as scheduled. During an interview on 2/3/2025 at 7:13 PM, LPN T confirmed Resident #317's hair was not groomed and combed. During an interview on 2/3/2025 at 7:20 PM, LPN U confirmed all residents should be groomed with hair combed daily. During an interview on 2/3/2025 at 9:17 PM, the Director of Nursing (DON) confirmed female residents' hair should be combed (groomed) daily. 46047 49269

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide appropriate services and treatment for an indwelling urinary catheter for 1 of 3 (Resident #317) reviewed for the use of a urinary catheter care, when the facility failed to obtain an order, failed to revise the care plan for the use of an indwelling urinary catheter, and when 1 of 1 (Certified Nursing Assistant (CNA) HH) failed to perform hand hygiene during catheter care. The findings include: 1. Review of the facility policy titled, Indwelling (Foley) Catheter Insertion, Female Resident dated 5/19/2023, revealed .Verify that there is a physician's order . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and resident's conditions are changed .reviews and updates the care plan .when there has been a significant change in condition in the residents condition .when the resident has been readmitted to the facility from a hospital stay . Review of the facility's policy titled, Handwashing Hand Hygiene, dated 1/27/2025, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Hand hygiene is indicated .after contact with blood, body fluids, or contaminated surfaces .before moving from work on a soiled body site to a clean body site on the same resident .immediately after removing gloves .The use of gloves does not replace hand washing/hand hygiene .Applying and Removing Gloves .Perform hand hygiene before applying gloves . 2. Review medical record revealed Resident #317 was admitted to the facility on [DATE], with diagnoses including Cerebral Vascular Accident (Stroke), Dysphagia, and Percutaneous Endoscopy Gastrostomy (PEG) tube. Review of the Admission/Readmission Evaluation dated 1/17/2025, revealed, Resident #317 returned to the facility with an indwelling urinary catheter. Review of the admission Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 4, which indicated Resident #317 had severe cognitive impairment. Review of the medical record revealed Resident #317 did not have a physician's order for the use of an indwelling urinary catheter until 1/27/2025 (during the survey). Review of the Care Plan dated 1/17/2025, revealed Resident #317 was not care planned for the use of an indwelling urinary catheter until 1/27/2025 (during the survey). Observations in Resident #317's room on 1/30/2025 at 8:02 AM and 1/31/2025 at 7:51 AM, revealed Resident #317 had an indwelling urinary catheter. During an interview on 2/3/2025 at 10:26 AM, Licensed Practical Nurse (LPN U) confirmed Resident #317 returned to the facility on [DATE], with an indwelling urinary catheter and an order should have been put in for the use when she returned to the facility. Observation on 2/3/2025 at 5:26 PM, revealed CNA HH provided incontinent stool care for Resident #317, removed her gloves, failed to perform hand hygiene before donning another pair of gloves, and proceeded to provide catheter care. During an interview on 2/3/2025 at 8:58 PM, the Director of Nursing (DON) confirmed that the facility must obtain an order for the use of an indwelling urinary catheter and must revise the care plan for the use of an indwelling urinary catheter. The DON confirmed staff should perform hand hygiene before and after removing gloves.

Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, facility investigation review, and interview, the facility failed to protect the resident's right to be free from neglect for 1 of 22 (Resident #319) sampled residents reviewed for abuse. The facility's failure to provide the necessary structure and processes to meet the care needs of Resident #319 resulted in actual HARM when Resident #319 fell from the bed and sustained a left hip fracture. Staff failed to provide 2-person assistance during incontinent care, for a cognitively impaired resident with contractures (a permanent tightening of muscle, tendons, skin, and surrounding tissue that causes the joints to shorten and stiffen) and hemiparesis (paralysis and partial weakness of one side of the body). Staff failed to ensure Resident #319 was monitored for adverse outcomes related to the witnessed fall. Resident #319 remained in the facility with a major injury for 1 day before receiving treatment. On [DATE], Resident #319 was sent out to the Emergency Department (ED) for evaluation of neurological symptoms and the facility failed to report information related to the fall that occurred on [DATE] to the receiving facility and ensure safe transition of care. The facility also failed to ensure 2 of 22 (Resident #56 and Resident #81) residents reviewed for abuse were free from verbal abuse when Certified Nursing Assistant (CNA) #11 made verbal threats and derogatory statements to them on [DATE]. The failure of the facility to prevent resident abuse resulted in psychosocial HARM for Resident #56 and Resident #81. The findings include: Review of the facility's policy titled, .Fall Management, revised ,d+[DATE] revealed, .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review .Care Plan updated as appropriate .Fall Event .When a fall occurs, the resident is assessed for injuries by the nurse .Complete an Incident/Accident Report .Complete .Progress Note .Add the fall event to 24-Hour Report .Initiate the Interdisciplinary Post-Fall Review .communicates resident falls to the attending physician .will discuss recommended interventions to reduce the potential for falls for the resident .IDT reviews all falls within ,d+[DATE] hours .IDT designee will discuss recommended significant changes .care plan will be reviewed and/or revised as indicated . Review of the policy titled, MDS [MDS Assessment] revised ,d+[DATE] revealed, .The Purpose of the Assessment .Is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs .The information derived from the MDS assessment is then used to assist the staff to care plan for the resident, so the resident may achieve/maintain their highest level of daily function . Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date ,d+[DATE], revealed, .Residents have the right to be free from abuse, neglect .Protect residents from abuse, neglect .by anyone including, but not necessarily limited to .facility staff .staff from other agencies .Develop and implement policies and protocols to prevent and identify .abuse or mistreatment of residents .neglect of residents .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems .Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting or abuse, stress management, and handling verbally or physically aggressive resident behavior .Identify and investigate all possible incidents of abuse, mistreatment .Investigate and report any allegations within timeframes required by federal requirements .Protect residents from any further harm during investigations . Review of the CMS RAI Version 3.0 Manual dated ,d+[DATE] revealed, . Section G0110: Activities of Daily Living Assistance dated ,d+[DATE] revealed, .How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction (late effects of stroke), Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease and Seizures. Review of the care plan for Resident #319 revealed, XXX[DATE] .at risk for falls r/t [related/to] stroke XXX[DATE] .on an platelet inhibitor XXX[DATE] .communicate best with yes/no questions post-stroke XXX[DATE] .chronic pain r/t Chronic Physical Disability XXX[DATE] .contractures XXX[DATE] .require assist with activities of daily living XXX[DATE] air mattress monitor placement and function XXX[DATE] Patient to wear LLE [Lower Left Extremity] knee extension [device to allow extension of lower extremity] daily as tolerated XXX[DATE] .Bed Mobility .Total Assist x [times] 2 Staff XXX[DATE] .Toilet Use .Total Dependence x 1 Staff XXX[DATE] Transfers .Totally Dependent x 2 Staff (Mechanical Lift) XXX[DATE] Remove air mattress . Continued review revealed there was no focus or interventions for Seizure diagnosis and no focus or interventions for risks associated with behaviors of jerking motions or spasms during care.There were no safety interventions for the air mattress included in the care plan. Review of Resident #319's Order Summary revealed, XXX[DATE] .Air Mattress-Monitor QShift [every shift] for Placement and Function XXX[DATE] .levETIRActam [anticonvulsant medication] Tablet 500 MG [milligram] two times a day for seizures . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #319 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and hygiene), total dependence with two persons physical assist for transfer (how resident moves between surfaces including to or from the bed, chair, wheelchair, or standing position (excludes to/from bath/toilet), total dependence with one-person physical assist for toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes) and required extensive assistance with two person physical assist for personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). Continued review revealed Resident #319 was always incontinent of bowel and bladder. Resident #319 had active diagnoses which included Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke, Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy, Muscle Weakness, and Other Lack of Coordination. Resident #319 had a pressure reducing device to the bed. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated [DATE] at 10:18 AM, revealed, .Incident Description: Resident was lying on side receiving patient care per CNA .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed. Lower body was tense and appeared to be spasming .Level of Pain .5 .Mental Status .Lack of Safety Awareness .Predisposing Physiological Factors .Cognitive Impairment .Extremity Weakness-Upper .Communication Deficit .Extremity Weakness-Lower .Incontinent .Predisposing Situation Factors .History of Falls .Side Rails Up .No Witnesses found . Resident 319's fall was witnessed by the roommate and CNA#6. Review of the nursing progress notes for Resident #319 dated [DATE] through [DATE], revealed no documentation of monitoring/assessment for changes related to Resident #319's witnessed fall on [DATE] at 10:18 AM. Review of the facility eINTERACT [facility documentation tool] Transfer Form , dated [DATE] at 4:47 PM, revealed Resident #319 was sent to Hospital #2 for numbness on left side of head. Resident Representative and Medical Director (MD) were notified. Director of Nursing [Former DON #1] completed the transfer form and Licensed Practical Nurse [LPN] #36 called report to Hospital #2 at 4:34 PM. There was no documentation related to Resident #319's fall on [DATE] on the transfer form. Review of Hospital #2's Emergency Department [ED]records for Resident #319 dated [DATE] revealed, .CHIEF COMPLAINT .came by ems [Emergency Medical Service] from snf [Skilled Nursing Facility] #1 for numbness on the top of his head for 3 days .possible stroke .HISTORY OF PRESENT ILLNESS .He states that yesterday, he was pushed off of his bed by a CNA. He hurt his left hip, low back, and hit his head .XR[Xray] Hip 2 or 3 Views Left with Pelvis .IMPRESSION: Comminuted [bone broken into more than two pieces] fracture LEFT femoral neck extending to the lesser trochanter [left hip fracture] .Impressions the patient has a left femoral neck fracture from his fall . Review of the employee record for CNA #6 revealed no documented training for Activities of Daily Living (ADL) Care (DON #1 stated CNA #6 received training on ADLs with return demonstration). Review of the facility investigation statement dated [DATE], revealed, .Interview with [Resident #319]: Admin [Administration] and Social Services Director (SSD) #1 asked [Resident #319] to recall the incident he had spoken to [Named Family Member FM #14] about .[Resident #319] was asked to show how this incident occurred .SSD #1 turned her back to [Resident #319] and he placed both of his hands in a cupping motion underneath SSD #1's armpits and made a pushing motion away from [Resident #319]'s body . Review of the facility investigation statement dated [DATE], revealed, .Interview with [Resident #47] dated [DATE] .Admin and Social Services spoke to [Resident #47] concerning the incident. [Resident #47] said that he had witnessed his roommate fall to the floor with the staff member. He relayed that no pushing happened and that the lady [CNA#6] was changing him and he fell . Review of facility investigation statement dated [DATE] revealed, .[CNA #6] was asked by Admin and Social Services to recall the incident from yesterday [[DATE]]. She stated that she was performing patient care to [Named Resident #319]. She said that [Resident #319] was lying horizontal on his side on the bed when she was attempting to wipe [Resident #319]. She stated that [Resident #319] had jumped a little bit, enough to cause [Resident #319]'s legs to swing out of the bed. Review of the progress notes for Resident #319 dated [DATE] at 4:47 PM revealed, Registered Nurse (RN) #6 documented, .pt [patient] sent out due to family request. pt c/o [complained of] numbness on left side of head . During an interview on [DATE] at 3:35 PM, the Former DON #1 stated she went to Resident #319's room and completed a head-to-toe assessment when notified about the fall on [DATE]. (During interview with LPN #4 and CNA #6, they both denied the Former DON #1 was present in the room after Resident #319's fall.) The Former DON #1 stated, .When I entered the room, [Resident #319] was in a sitting position or maybe propped up against something .[Resident #319] rated his pain 5 of 10 to his left knee .[Resident #319] told me to just put him back in bed . The Former DON was asked if Resident #319 was provided an intervention for pain rated 5 of 10. The Former DON #1 replied, .[Resident #319] refused pain medication for pain in his knee and just wanted to be put back in bed . the Former DON #1 stated CNA #6 and LPN #4 were in the room and used a mechanical lift to place Resident #319 back in the bed. (During interview, LPN #4 and CNA #6 denied the use of a mechanical lift.) The Former DON #1 stated CNA #6 was performing incontinence care when Resident #319 slid off the bed. The Former DON was asked which way CNA #6 had Resident #319 turned for incontinence. The Former DON #1 replied, [Resident #319] was turned away from [CNA #6] and when [Resident #319] started to fall, I guess [CNA #6] came around to catch him. The Former DON #1 stated the CNAs are able to look at the Kardex for information involving residents' care plans. DON #1 was asked if nursing documented Resident 319's continuing assessment for changes post fall in the progress notes for Resident #319. She responded No, I am not sure what the policy is for follow up charting. During an interview on [DATE] at 10:17 AM, CNA #16 stated Resident #319 was incontinent and required a 2 person assist with a lift for transfers. CNA #16 stated, [Resident #319] would push back against you when he was rolled over and that's why I always used 2 people for his care, because it was safer. During an interview on [DATE] at 2:00 PM, the Rehab Director was asked what was included in assessment for bed mobility. He responded bed mobility included side to side, and sit to supine. The Rehab Director stated when a patient/resident is coded for 2-person assist for bed mobility, it would require a 2-person assist for incontinence care provided in bed. During a telephone interview on [DATE] at 9:05 AM, LPN #4 stated she was Resident #319's nurse on [DATE]. LPN #4 stated, .I was notified by [CNA #6] that [Resident #319] had fallen off the bed .the tech [CNA #6] stated [Resident #319] was turned on his side .His body tensed up and he threw his body onto the floor .This is not the first time he had the jerking movements during care .[Resident #319] said I don't know why I do this .LPN #4 stated, When I walked in the room, he was lying on the floor .It took several of us to get him up . LPN #4 was asked if she assessed Resident #319 on the floor. She responded, He had on a gown. I did not see any deformities. I tried to do what I could of a head-to-toe assessment while he was on the floor. When asked if a lift was used to put Resident #319 back in bed, LPN #4 replied, No. Three of us picked him up and placed him back in bed. LPN #4 stated DON #1 did not come to the room after the fall and complete an assessment. LPN #4 was asked ; have you received training to provide care of a patient on an air mattress. LPN #4 replied, No. LPN #4 was asked did Resident #319 require seizure precautions. LPN#4 responded, I don't think so. LPN #4 was asked if Resident #319 was care planned for jerking movements . LPN #4 replied, Yes, keep bed in lowest position. No interventions in place for jerking behaviors on current care plan. LPN #4 stated CNA #6 should have requested help when [Resident #319] clinched up (became stiff). LPN #4 was asked if there had been 2 CNAs providing incontinence care for Resident #319, would that have prevented the fall . LPN #4 replied, Yes. During a telephone interview on [DATE] at 11:02 AM, CNA #6 stated, .I was giving patient care and [Resident #319] was turned away from me .He jumped when I was cleaning his bottom .He has jumped before related to pain . CNA #6 stated, .I reached back to get some cream with one hand and kept the other hand on [Resident #319] and that's when he fell .[Resident #319] stiffened up and threw his legs off the bed .I jumped across the bed and grabbed him under his arms .[Resident #319] had jerking movements during care, that wasn't unusual. CNA #6 was asked if another CNA [2-person assist] had been present while performing incontinence care on Resident #319, would that have prevented Resident #319 from falling . CNA #6 replied, Yes, two people could have stopped him from falling .His care plan said 1 person assist . CNA #6 was asked if she was one of the 3 people that picked Resident #319 up from the floor ? CNA #6 responded, Yes, we did pick him up and he was groaning from pain. Further interview revealed CNA#6 received no training on ADL care of residents on an air mattress at SNF #1. During an interview on [DATE] at 11:16 AM, FM #14 stated, .[Resident #319] is paralyzed on the left side. FM #14 was asked if she had Resident #319 sent out to the hospital for symptoms of a stroke . FM #14 responded, .No, when I walked in that room, he started crying .He was in so much pain .I asked them then, are y'all going to send him out for Xray .The nurse said he doesn't have any broken bones .That's when I demanded [Resident #319] to be sent to the emergency room [ER] .He had not had another stroke; he had a broken hip .I talked to his roommate [Resident #47], he was in his right mind .[Named Resident #47] said [Resident #319] hit the floor .[SNF #1] said he never hit the floor . During a telephone interview on [DATE] at 4:15 PM, the SSD #1 stated, .During an interview on [DATE], I asked [Named Resident #319] to demonstrate how the CNA lowered him to the floor .I backed up to the bed and [Resident #319] extended his arms and reached under my arms like he was catching me . During an interview on [DATE] at 12:45 PM, the Former DON #1 stated the Interdisciplinary Team (IDT) investigated Resident #319's fall on [DATE] and determined the air mattress on his bed had contributed to him sliding off the bed due to him moving around and an air mattress being slick. The Former DON #1 stated residents on an air mattress should have a care plan with interventions in place. When asked what type of interventions would need to be implemented, Former DON #1 replied, .check placement and functioning, and do not use fitted sheets . When asked what is meant by placement and functioning of an air mattress, Former DON #1 replied, Placement is making sure the resident actually has the air mattress, the resident could have moved rooms and the mattress did not follow .Functioning means is the air mattress turned on, is it inflated. When asked if sheets should be used on an air mattress, the Former DON #1 replied, No, fitted sheets would prevent the mattress from properly inflating and could possibly turn off the CPR [Cardiopulmonary Resuscitation] function [This allows for a proper hard surface needed in which to initiate chest compressions and intubation]. The Former DON #1 stated she could not think of any safety interventions that would need to be implemented for use of an air mattress. Continued interview revealed the Former DON #1 stated she was not aware of Resident #319 having a diagnosis for seizures. The Former DON #1 stated she would expect his care plan to reflect a diagnosis for seizures with interventions implemented. DON #1 was unable to provide documentation related to a root cause analysis and investigation related to Resident #319's [DATE] fall. The Former DON #1 reviewed the transfer form dated [DATE] for Resident #319 and stated.The fall was not documented on the transfer form because [Resident #319] was not sent out for symptoms related to the fall . When asked if the information related to the fall on [DATE] was relevant information due to Resident #319 being transferred to the ER for symptoms of numbness of the scalp. The Former DON #1 replied, No. During an interview on [DATE] at 10:40 AM, the MDS Coordinator was asked to review Resident #319's quarterly assessment dated [DATE]. The MDS Coordinator was asked how she determined Resident #319 required extensive assistance of 2 persons for bed mobility, total dependence for toileting one person assist, and extensive assist of 2 persons for personal hygiene. The MDS Coordinator stated, .I would review the staffing documentation and make visual observations. If I code a resident as total assistance, then the CNA documentation must say the resident required total assistance all the time during the 7 day look back period . The MDS Coordinator was asked how Resident #319 could require 2 person assist for personal hygiene and only require 1 person assist for toileting. The MDS Coordinator stated, .I am not the CNA that cared for him so I can't tell you that . The MDS Coordinator was asked if the CNA documentation was always correct. The MDS Coordinator stated, No. During an interview on [DATE] at 2:50 PM, The MDS Coordinator was asked if seizures were checked on Resident #319's Care Area Assessment (CAA) and Resident #319 was on seizure medication twice a day, should Resident #319 have been care planned for seizures. The MDS Coordinator responded, .Seizures should have been care planned since he was on seizure medication . The MDS Coordinator was then asked if a resident was on an air mattress, should safety measures be care planned. The MDS Coordinator stated, .I don't usually put safety measures in for an air mattress . During a telephone interview on [DATE] at 3:34 PM, LPN #36 stated he was the Unit Manager for 3rd floor on [DATE]. LPN #36 was unable to recall sending Resident #319 to theER on [DATE] and stated, .I always assisted the nurse during a transfer by calling report to the receiving facility .I used the Interact transfer form as a guide when calling report, and sent a copy of the form with the resident to the ER . The surveyor asked LPN #36 if information related to a fall the previous day would be included in the report to the receiving facility . LPN #36 replied, Yes. LPN #36 stated if he had known about Resident #319's fall on [DATE], he would have included it on the transfer form and in the call for report. LPN #36 stated if the information about the fall was not noted on the transfer form for Resident #319, then he was unaware of the fall. During an interview on [DATE] at 12:13 PM, Nurse Practitioner (NP) #3 stated she had no record that she or any other of the NP's at the facility had assessed Resident #319 after the fall on [DATE] . The facility failed to provide 2 person assistance during incontinence care that resulted Resident 319's fall with hip fracture. The facility failed to perform a thorough assessment after the fall, that led to Resident 319's delay of treatment until the following day. The facility failed to notify the receiving facility of Resident 319's fall with injury. ________________________________ Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, Osteomyelitis, and Type 2 Diabetes Mellitus. Review of the comprehensive care plan dated [DATE] Resident #56 revealed, .Focus Resident requires assist with activities of daily living .Interventions/Tasks .Roll left and right .Substantial/maximal assistance X 1 staff .Shower/Bathe self .Substantial/maximal assistance x 1 staff .Toileting hygiene .Substantial/maximal assistance required x 1 staff .Focus Mood/Behavior: I'm at risk of a change in my mood and behavior due to my diagnosis of MDD [Major Depressive Disorder] and anxiety disorder .Goal My behavior will not cause distress to myself and others .Interventions/Tasks .Encourage me to voice my feelings, fears, and concerns .Observe me for changes in my mood that may put me at risk for behaviors to occur .Provide me supportive listening and communication . Review of the Psychological Diagnostic Interview for Resident #56 dated [DATE] revealed, .[Named Resident #56] is being seen today for follow-up regarding any emotional needs since he reportedly observed verbal abuse of his roommate from a CNA, who is no longer in the facility .He was able to describe the events that occurred recently . Review of the Quarterly MDS dated [DATE] revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #56 was dependent for toileting, personal hygiene, and bathing which required extensive assistance of one person. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare following surgical amputation, Type 2 Diabetes Mellitus, and Congestive Heart Failure (CHF). Review of the Psychological Diagnostic Interview for Resident #81 dated [DATE] revealed, .[Resident #81] related events related to the abuse, saying that he didn't sleep the night of the event, saying he was fearful for his safety . Review of the comprehensive care plan dated [DATE] Resident #81 revealed, .Focus Abuse/Neglect: I'm at risk for actual/potential abuse/neglect related to my dependence on others for ADL care .Goal I will not experience any form of abuse or neglect through review date .Interventions/Tasks Provide assistance with ADL's as needed .Provide support and ensure resident is free from abuse and/or neglect . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #81 had a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #81 was dependent for toileting, supervision related to personal hygiene, and substantial/maximum assistance with rolling left and right, sit to lying, and lying to sitting on side of bed. Review of the facility investigation dated [DATE] revealed, .Date/Time/Name of when staff became aware of this incident XXX[DATE] at 2:15 PM .Date/Time administrator was notified of the incident XXX[DATE] 2:35 PM .Date and time when the alleged incident occurred [DATE] 11:00 PM .[Named Resident #81] (BIM Brief Interview for Mental Status - 15) reported to the Unit Manager that he had a confrontation with his night shift [7:00 PM-7:00 AM [DATE]] CNA. Resident reported that the confrontation had arisen during a periodic check around midnight by the alleged perpetrator. Resident stated that he was upset with the frequency in which the same [CNA ] had made rounds to check on him. Resident stated that the CNA was very argumentative and made a threatening remark when exiting the room. Resident has displayed no signs of psychosocial distress or harm .Residents roommate [Named Resident #56 BIM-15] corroborated [Named Resident #81 BIM - 15] allegation against CNA when questioned by administration .Administrator conducted a phone interview with the alleged perpetrator, [Named CNA #11], on [DATE] regarding the alleged incident. [Named CNA #11] stated that she mistakenly had thought that the Resident was independent with ADLs. [Named CNA #11] stated that when she checked on [Named Resident #81] around midnight he became very upset. [Named CNA #11] states [Named Resident #81] started cursing her out so she exited the room. [Named CNA #11] denied making any threatening statement to the Resident during the interaction . Continued review of the facility investigation revealed a written statement completed by Unit Manager [LPN #19] which stated, .Tech [CNA #11] came @ [at] 11[11:00 PM] - told them they were independent, told [Named Resident #81] she was brand new, he told her she still had to check them. She said 'you don't tell me what to do' 'I'll kick your ass, slamed [slammed] the bathroom door he sadi [said] '[expletive] you try it' She said '[expletive] you mother [expletive]', you can suck my ass' after confrontation She never came back 12 pm-7 am .She called [Resident #56] a'mfer' [expletive] . Review of the facility investigation revealed the allegation of abuse occurred on [DATE] around 11:00 PM - 12:00 AM [midnight] and was not reported to the Administrator until [DATE] at 2:35 PM. Review of CNA #11's employee clock in and clock out for [DATE] revealed the employee clocked in at 7:04 PM on [DATE] and clocked out at 7:03 AM on [DATE]. The allegation of abuse reported by Resident #81 revealed the interaction with the employee occurred around 11:00 PM - 12:00 AM on [DATE]. The employee clock in and clock out revealed CNA #11 worked the remainder of the shift past the time of the allegation of the verbal abuse. Review of Police Department #1's Incident Report dated [DATE] revealed, Dispatched .Report Date [DATE] .Victim [Named Resident #81] .Victim to Suspect Number 1 [Named CNA #11] .Complainant .[Named Administrator] .Narrative .[Named SNF #1] administrator .reported the following incident at the facility. [Resident #81] stated that on [DATE] at approximately 11:00pm [PM] he got into an argument with employee [CNA #11] employed at the facility. During the argument [Named CNA #11] allegedly said to [Named Resident #81] 'I'll kick your ass' . During an interview on [DATE] at 11:34 AM , Former DON #1 and Administrator confirmed they were notified of the allegation of verbal abuse on [DATE]. The Former DON #1 stated, .The written statement in the investigation was the Unit Manager's [LPN #19] statement of what [Named Resident #81] reported . The Administrator was asked if Resident #81's roommate (Resident #56) or any other employees that worked that shift were interviewed . The Administrator replied, If I had interviewed the roommate, it would be in the investigation. I didn't ask anyone else because they were not in ear shot, I would have thought the roommate would have been interviewed. I think the roommate was interviewed by the SSD. When I called [Named CNA #11] she had an attitude with me. I just had what [Named Resident #81] reported and it was conflicted with what [Named CNA #11] said happened. I was not aware [Named Resident #81] said he didn't sleep the night of the event and was fearful for his safety. The supervisor [LPN #26] for [DATE] denied knowing anything about it . During an interview on [DATE] at 12:20 PM, Resident #81 stated, . [Named CNA #11] threatened us, slammed the door, [Named CNA #2] another tech took care of me and my roommate the rest of the night. [Named CNA #11] never came in our room to check on us until 11:00 PM that night [[DATE]]. When [named CNA #11] came in the room I said 'are you not supposed to check on us every 2 hours.' The CNA told me to shut up and threatened to kick my ass. I did tell her [expletive] you and then [Named CNA #11] said suck my ass, no one wants to take care of you, she slammed the door so hard the clock almost fell off the wall. I told the supervisor that night, I can't remember the supervisor's name, but the [CNA #11] wasn't sent home. I saw [CNA #11] in the hallway about 12:00 AM and 1:00 AM . The night nurse was an agency nurse, she knew about what happened. I stayed up all night because I was scared, and my roommate was scared. I never seen anybody get that angry, they should have sent her home. I am pretty sure she worked all night. The supervisor on night shift didn't do anything. [Named CNA #11] called my roommate a mother [expletive] . During an interview on [DATE] at 12:55 PM, Resident #56 (Resident #81's roommate) stated, .[CNA #11] came in here about 11:00 PM [[DATE]], my roommate asked her why she was just now checking on us. [CNA #11] said she thought we could take care of ourselves. [CNA #11] was standing in the bathroom, yelling, woke me up, the CNA told my roommate to suck her ass and slammed the door. Resident #56 stated, .I didn't trust the girl, I was afraid she would hurt us .I s [TRUNCATED]

Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, review of the facility incident report, facility investigation, review of Hospital #2's Emergency Department (ED) records, medical record review, and interview, the facility failed to ensure a person-centered care plan was developed and implemented for 1 of 11 (Resident #319) sampled residents reviewed using an air mattress. The facility's failure to develop and implement a person-centered care plan for Resident #319 resulted in actual harm when he fell from the bed during incontinence care and sustained a left hip fracture. The findings include: Review of the policy titled, MDS [Minimum Data Set] Assessment revised ,d+[DATE] revealed .The Purpose of the Assessment .Is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs .The information derived from the MDS assessment is then used to assist the staff to care plan for the resident, so the resident may achieve/maintain their highest level of daily function . The facility was unable to provide the facility policy titled Care Plans, Comprehensive Person-Centered dated 2022 . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated [DATE], revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the CMS RAI Version 3.0 Manual dated ,d+[DATE] revealed, .Section G0110: Activities of Daily Living (ADL) Assistance .How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease and Other Seizures. Review of an Order Summary revealed, XXX[DATE] .Air Mattress-Monitor QShift [every shift] for Placement and Function XXX[DATE] .levETIRActam [anticonvulsant medication] Tablet 500 MG [milligram] two times a day for seizures . Review of the Annual MDS dated [DATE] revealed Resident #319 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and hygiene), total dependence with two persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Resident #319 was coded always incontinent of bowel and bladder. Resident #319 had active diagnoses which included Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke, Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy, Muscle Weakness, Other Lack of Coordination. Resident #319 had a pressure reducing device to the bed. Review of the care plan for Resident #319 revealed, XXX[DATE] .require assist with activities of daily living XXX[DATE] .at risk for falls r/t [related to] stroke XXX[DATE] .communicate best with yes/no questions post-stroke XXX[DATE] .chronic pain r/t Chronic Physical Disability XXX[DATE] .on an platelet inhibitor XXX[DATE] .contractures XXX[DATE] Patient to wear LLE [Left Lower Extremity] knee extension daily as tolerated XXX[DATE] air mattress monitor placement and function [no safety interventions implemented] XXX[DATE] .Bed Mobility .Total Assist x [times] 2 Staff .Transfers .Totally Dependent x 2 Staff (Mechanical Lift) XXX[DATE] Remove air mattress . Continued review revealed there was no focus or interventions for the Seizure diagnosis and no focus or interventions for risks associated with behaviors of jerking motions or spasms during care. Review of the Quarterly MDS dated [DATE] revealed Resident #319 had an unchanged BIMS score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility, total dependence with two persons physical assist for transfer. Resident #319 was coded always incontinent of bowel and bladder. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated [DATE] at 10:18 AM revealed, .Incident Description: Resident was lying on side receiving patient care per Certified Nursing Assistant [CNA] .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed. Lower body was tense and appeared to be spasming .did not hit his head and denies pain anywhere other than his left knee .No injuries observed at time of incident .Level of Pain .5 .Mental Status .Lack of Safety Awareness .Predisposing Physiological Factors .Cognitive Impairment .Extremity Weakness-Upper .Communication Deficit .Extremity Weakness-Lower .Incontinent .Predisposing Situation Factors .History of Falls .Side Rails Up .No Witnesses found . The facility event incident report incorrectly stated no witnesses were found. There were two witnesses to the fall, CNA#6 and Resident 319's roommate witnessed the fall. Review of Hospital #2's ED Records for Resident #319 dated [DATE] , revealed, .CHIEF COMPLAINT .came by ems [Emergency Medical Service] from snf [Skilled Nursing Facility #1] for numbness on the top of his head for 3 days .possible stroke .HISTORY OF PRESENT ILLNESS .He states that yesterday, he was pushed off of his bed by a CNA. He hurt his left hip, low back, and hit his head .XR [Xray] Hip 2 or 3 Views Left with Pelvis .IMPRESSION: Comminuted [bone broken into more than two pieces] fracture LEFT femoral neck extending to the lesser trochanter [left hip fracture] .Impressions: the patient has a left femoral neck fracture from his fall . Review of a facility investigation statement dated [DATE] revealed, .Interview with Resident #47 dated [DATE], revealed, Admin [Administration] and Social Services spoke to [Resident #47] concerning the incident. [Resident #47] said that he had witnessed his roommate fall to the floor. Resident #47 stated, .the lady [CNA#6] was changing him, and he fell . Review of a facility investigation statement dated [DATE] revealed, . [CNA #6] was asked by Admin [Administration] and Social Services to recall the incident from yesterday [[DATE]]. She stated that she was performing patient care to [Resident #319]. She said that [Resident #319] was lying horizontal on his side on the air mattress when she was attempting to wipe [bowel incontinent care]. She stated that [Resident #319] had 'jumped a little bit', enough to cause [Resident #319]'s 'legs to swing out of the bed'. During an interview on [DATE] at 3:35 PM, Former Director of Nursing (DON) #1 stated she went to Resident #319's room and completed a head-to-toe assessment when notified about the fall on [DATE]. Former DON #1 stated CNA #6 was performing incontinence care after Resident #319 had an incontinent episode, when Resident #319 slid off the bed. When asked which way CNA #6 had Resident #319 turned for incontinent care, Former DON #1 replied, [Resident #319] was turned away from [CNA #6] and when [Resident #319] started to fall, I guess [CNA #6] came around to catch him. During an interview on [DATE] at 10:17 AM, CNA #16 stated Resident #319 was incontinent and required a 2 person assist with a lift for transfers. CNA #16 stated, [Resident #319] would push back against you when he was rolled over and that's why I always used 2 people for his care, because it was safer. During an interview on [DATE] at 11:13 AM, the Occupational Therapist (OT) stated Resident #319 was on and off therapy from 2019 through 2022 and fluctuated frequently with his care. When asked about bed mobility, the OT stated this would include supine [lying face upward] to sit, which would require 2 persons assist During an interview on [DATE] at 2:00 PM, the Rehab Director was asked what was included in an assessment for bed mobility . He responded bed mobility included side to side, and sit to supine. The Rehab Director stated when a patient/resident is coded for 2-person assist for bed mobility, it would require a 2-person assist for incontinence care provided in bed. During a telephone interview on [DATE] at 9:05 AM, Licensed Practical Nurse (LPN ) #4 stated she was Resident #319's nurse on [DATE]. LPN #4 stated, .I was notified by [CNA #6] that [Resident #319] had fallen off the bed .the tech (CNA #6) stated [Resident #319] was turned on his side .His body tensed up and he threw his body onto the floor .This is not the first time he had the jerking movements during care .LPN #4 stated, When I walked in the room, he was lying on the floor .It took several of us to get him up . LPN #4 was asked, did you assess [Resident #319] on the floor. She responded, He had on a gown. I did not see any deformities. I tried to do what I could of a head-to-toe assessment while he was on the floor. When asked if a lift was used to put Resident #319 back in bed, LPN #4 replied, No, three of us picked him up and placed him back in bed. LPN #4 stated, The [Former DON #1] did not come to the room after the fall and complete an assessment. LPN #4 was asked if she had been trained on providing patient care for a patient on an air mattress. LPN #4 replied, No. LPN #4 was asked if Resident #319 required seizure precautions. She responded, I don't think so. LPN #4 was asked if Resident #319 was care planned for jerking movements. LPN #4 replied, Yes, keep bed in lowest position. LPN #4 further stated, [CNA #6] should have requested help when [Resident #319] clinched [stiffened] up. LPN #4 was asked if there had been 2 CNAs providing incontinence care for Resident #319, would that have prevented the fall. LPN #4 replied, Yes. There were no interventions in place for jerking behaviors on the current care plan. A mechanical lift was not used to transfer Resident #319 from the floor to the bed. During a telephone interview on [DATE] at 11:02 AM, CNA #6 stated, .I was giving patient care and [Resident #319] was turned away from me .He jumped when I was cleaning his bottom .He has jumped before related to pain . CNA #6 stated, .I reached back to get some cream with one hand and kept the other hand on [Resident #319] and that's when he fell .[Resident #319] stiffened up and threw his legs off the bed .I jumped across the bed and grabbed him .[Resident #319] had jerking movements during care, that wasn't unusual. CNA #6 was asked if there had been another CNA with her while performing incontinence care on Resident #319, would that have prevented Resident #319 from falling out of the bed. CNA #6 replied, Yes, two people could have stopped him from falling .His care plan said 1 person assist . CNA #6 was asked if she was one of the 3 people that picked Resident #319 up off the floor. CNA #6 responded, Yes, we did pick him up and he was groaning from pain. During an interview on [DATE] at 12:45 PM, Former DON #1 stated the Interdisciplinary Team (IDT) investigated Resident #319's fall on [DATE] and determined the air mattress on his bed had contributed to him sliding off the bed due to him moving around and an air mattress being slick. Former DON #1 stated residents on an air mattress should have a care plan with interventions in place. When asked what type of interventions would need to be implemented, Former DON #1 replied, .check placement and functioning, and do not use fitted sheets . When asked what is meant by placement and functioning of an air mattress, the Former DON #1 replied, Placement is making sure the resident actually has the air mattress, the resident could have moved rooms and the mattress did not follow .Functioning means is the air mattress turned on, is it inflated. When asked if sheets should be used on an air mattress, the Former DON #1 replied, No, fitted sheets would prevent the mattress from properly inflating and could possibly turn off the CPR [Cardiopulmonary Resuscitation] function [This function allows for an instant deflation providing a hard surface needed for chest compressions and intubation]. Former DON #1 stated she could not think of any safety interventions that would need to be implemented for use of an air mattress. The Former DON #1 was asked if [Resident #319] had seizure precautions in place. Former DON #1 stated she was not aware of Resident #319 having a diagnosis for seizures. Former DON #1 stated she would expect his care plan to reflect a diagnosis for seizures with interventions implemented. During an interview on [DATE] at 10:40 AM and [DATE] at 2:50 PM, the MDS Coordinator was asked to review Resident #319's quarterly assessment dated [DATE]. The MDS Coordinator was asked how she determined Resident #319 required extensive assistance of 2 persons for bed mobility, total dependence for toileting one person assist, and extensive assist of 2 persons for personal hygiene. The MDS Coordinator stated, .I would review the staffing documentation and make visual observations. If I code a resident as total assistance, then the CNA documentation must say the resident required total assistance all the time during the 7 day look back period . The MDS Coordinator was asked how Resident #319 could require 2 person assist for personal hygiene and only require 1 person assist for toileting. The MDS Coordinator stated, .I am not the CNA that cared for him so I can't tell you that . The MDS Coordinator was asked if the CNA documentation was always correct. The MDS Coordinator stated, No. The MDS Coordinator was asked if seizures were checked on Resident #319's Care Area Assessment (CAA) and Resident #319 was on seizure medication twice a day, should Resident #319 have been care planned for seizures. The MDS Coordinator responded, .Seizures should have been care planned since he was on seizure medication . The MDS Coordinator was then asked if a resident was on an air mattress, should safety measures be care planned. The MDS Coordinator stated, .I don't usually put safety measures in for an air mattress . The facility failed to implement the plan of care (2 person assistance for bed mobility/incontinent care) that resulted in Resident #319's fall out of the bed and sustained a hip fracture. The facility failed to establish interventions for the Seizure diagnosis or for risks associated with behaviors of jerking motions or spasms during care.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide effective pain management for 2 (Resident #221 and #224) of 5 residents reviewed for pain. The facility's failure to implement an effective pain management program for Resident #221 and Resident #224 resulted in an increase in pain and actual HARM to Resident #221 and Resident #224. The findings include: Review of the facility policy titled, Pain Assessment and Management, dated 5/19/2023 revealed, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .1. Observe the resident [during rest and movement] for physiologic .signs of pain. 2. Possible Behavioral Signs of Pain .a. negative verbalizations and vocalizations such as groaning .b. facial expressions such as grimacing, frowning .4. Ask the resident if he/she is experiencing pain .Identifying the Causes of Pain .1. Residents may experience pain from several different causes simultaneously. 2. In addition, common procedures such as moving the resident, physical therapies .3. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including .fractures .end of life/hospice care .Establish a treatment regimen that is specific to the resident based on consideration of the following: a. The resident's medical condition .b. Current medication regimen .f. treatment goals .Administering medications around the clock rather than PRN [as needed] . Review of the medical record revealed Resident #221 was admitted to the facility on [DATE] with diagnoses which included Unspecified Trochanteric Fracture of Left Femur, and Type 2 Diabetes Mellitus. Review of baseline care plan dated 1/26/2024 for Resident #221 revealed, .The resident has greater trochanter left femur fracture r/t [related/to] fall .Goal The resident will remain free of complications related to hip fracture, such as contracture formation .Interventions/Tasks .Anticipate and meet needs .Follow MD [Medical Doctor] orders for weight bearing status. See MD and/or PT [Physical Therapy] treatment plan .impaired mobility, Unrelieved pain .PT/OT [Occupational Therapy] evaluation and treatment per orders .Focus At risk for pain related to Acute Illness, Recent Change in Condition-Requiring Skilled Nursing Home Placement, Recent hospitalization .Goal The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain .Interventions/Tasks .Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain .Vocalizations (grunting, moans, yelling out . Review of the Medication Administration (Admin) Audit Report dated January 2024 for Resident #221 revealed an order for Oxycodone Hydrochloride (HCL) (opioid medication used medically for treatment of moderate to severe pain) Oral Tablet 5 milligram (mg) give 5 mg by mouth four times a day for Chronic Pain and Acetaminophen 500 mg give 1 tablet by mouth three times a day for pain with a scheduled time for 1/30/2024 at 9:00 AM. Further review of the Medication Admin Audit Report revealed on 1/30/2024 Oxycodone HCL 5 mg tablet and Acetaminophen 500 mg tablet was administered at 11:34 AM by Licensed Practical Nurse (LPN) #44. The audit report revealed Resident #221's pain medications were administered 1 hour and 34 minutes late. During an observation on the 200 hall on 1/30/2023 at 11:00 AM, Resident #221 was observed walking with his walker with assistance of OT #2 back to his room. Resident #221 requested his pain medication in the hall. OT #2 assisted Resident #221 to the side of his bed to sit down. Resident #221 with a facial grimace, groaned loudly when he sat down on the side of his bed. During an interview on 1/30/2024 at 11:10 AM, OT #2 was asked if Resident #221 received his pain medication prior to his therapy this morning. OT #2 stated, No. OT #2 was asked if Resident #221 was able to complete his therapy session. OT #2 stated, .he was unable to complete all the transfer training. He did complain of pain during his therapy session . During an interview on 1/30/2024 at 11:15 AM with Licensed Practical Nurse (LPN) #44, she was asked why Resident #221 was unable to receive his pain medication prior to his therapy. LPN #44 stated, .this is my first day to be at the facility .I work for agency .I was unable to sign on to the computer to be able to start my medications this morning . LPN #44 stated, .basically all my medications were late this morning . LPN #44 was asked if any manager or other nurse stepped in to help her with the medication pass. LPN #44 stated, No. During an interview on 1/30/2024 at 1:00 PM, Resident #221 was asked about his care at the facility. Resident #221 stated, .my pain meds are late didn't get them this morning and its due again at 1:00 PM . I need my pain medication . The facility failed to provide agency staff with login information to the electronic medical record in a timely manner, therefore pain medication was not administered as ordered, which resulted in actual harm for Resident #221. Review of the medical record revealed Resident #224 was admitted to the facility on [DATE] with diagnoses which included Unspecified Cord Compression, Collapse Vertebra subsequent encounter for Fracture, Malignant Neoplasm of Unspecified Bronchus or Lung, Encounter for Palliative Care, Malignant Neoplasm of Spinal Cord, and Neoplasm related Pain (acute) (chronic). Review of the Admission MDS dated [DATE] for Resident #224 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #224 received scheduled pain medication and PRN pain medication over the last 5 days. Further review of the MDS revealed a pain assessment interview with a pain frequency of almost constantly. Review of the comprehensive care plan dated 1/12/2024 for Resident #224 revealed, .Focus Resident is at risk for neoplastic disorders Cancer of Lung and spinal cord .Interventions/Tasks .Monitor pain levels and administration pain meds .per MD [Medical Doctor] order .Focus At risk for pain related to .Chronic Illness .Interventions/Tasks .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Review of the Medication Admin Audit Report for Resident #224 revealed an order for Morphine Sulfate (opioid pain reliever) ER (extended release) 30 mg (milligram) give 1 tablet by mouth every 12 hours for pain with a scheduled time for 1/30/2024 at 8:00 AM. Continued review of the Medication Admin Audit Report revealed an order for Methocarbamol (muscle relaxant) 500 mg give 1.5 tablet by mouth four times a day for muscle spasm with a scheduled time for 1/30/2024 at 9:00 AM. Further review of the Medication Admin Audit Report revealed on 1/30/2024 Morphine Sulfate ER was administered at 13:05 PM by LPN #44 and Methocarbamol was administered at 13:06 PM. The audit report revealed Resident #224's pain medication was administered 4 hours and 5 minutes late and muscle relaxer was administered 3 hours and 6 minutes late. During an observation on the 200 halls on 1/30/2024 at 11:25 AM, Resident #224's call light was on. A housekeeper answered the call light and came out in the hall and told the Unit Manager (LPN #2) Resident #224 wanted her pain medication. During an observation on the 200 halls on 1/30/2024 at 11:30 PM, the Unit Manager (LPN #2) walked by this surveyor smiled and stated, The nurse is behind on her medications, but she is trying to get caught up. During an interview on 1/30/2024 at 12:00 PM, Resident #224 was asked why she had her call light turned on. Resident #224 stated, .My morning pain medication was late .I have Cancer I need my pain meds . Resident #224 was asked what her pain scale was on a scale from 1-10. Resident #224 stated, .It is a 9 but the medications help when I get them . During an interview on 2/6/2024 at 3:35 PM, Former DON #1 was asked if she received a text on 1/30/2024 that an agency nurse needed assistance with a login to the computer system. Former DON #1 looked at her cell phone and stated, .I received a text on 1/30/2024 at 8:28 AM, from the Unit Manager [LPN #2] saying the nurse needed the sign on stuff. I got the login for the nurse, and it usually is ready after 5 minutes . Former DON #1 was asked if it was normal for an agency nurse not to have her login information prior to her starting her shift. Former DON #1 stated, It would depend on who the on-call person was, if I were on call, I would look at the schedule and see if I needed to get one for a nurse. During an interview on 2/6/2024 at 7:55 AM, LPN #9 was asked if she was an agency nurse for the facility. LPN #9 stated, .I use to be an agency nurse but not now. I wasn't given any training prior to starting as an agency nurse. I had to wait to get a login for the computer system which makes it hard to start your medications . The facility failed to administer pain medications as ordered, which resulted in actual harm for Resident #224.

46831 Based on facility policy review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, facility eINTERACT Transfer Form review, medical record review, facility investigation review, and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provide supervision for 1 of 11 (Resident #319) sampled residents reviewed for assistance with Activities of Daily Living (ADL)s and air mattress use. The facility's failure to provide a safe environment during care resulted in actual harm when Resident #319 fell from bed and sustained a left hip fracture on [DATE] while receiving incontinence care with use of 1 person assist. The findings include: Review of the facility's policy titled, .Fall Management revised ,d+[DATE] revealed, .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review .When a fall occurs, the resident is assessed for injuries by the nurse .Complete an Incident/Accident Report .Complete SBAR [Situation, Background, Assessment, and Recommendation] Communication Form & Progress Note .Add the fall event to 24-Hour Report .Initiate the Interdisciplinary Post-Fall Review .communicates resident falls to the attending physician .will discuss recommended interventions to reduce the potential for falls for the resident .IDT reviews all falls within ,d+[DATE] hours .IDT designee will discuss recommended significant changes .care plan will be reviewed and/or revised as indicated . Review of the CMS RAI Version 3.0 Manual dated ,d+[DATE] revealed, .Section G0110: Activities of Daily Living (ADL) Assistance .How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting . Review of the facility's policy titled MDS [Minimum Data Set] Assessment, revised ,d+[DATE] revealed, .The Purpose of the Assessment .Is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity, as well as medical, cognitive, and emotional needs .The information derived from the MDS assessment is then used to assist the staff to care plan for the resident, so the resident may achieve/maintain their highest level of daily function . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated [DATE], revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the facility's policy titled, Accidents Incidents Investigating, dated [DATE] revealed, .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the administrator .b. The nature of the injury/illness .c. The circumstances surrounding the accident or incident .k. Any corrective action taken . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease and Other Seizures. Review of the Physician's Orders revealed, XXX[DATE] .Air Mattress-Monitor QShift [every shift] for Placement and Function XXX[DATE] .levETIRActam [anticonvulsant medication] Tablet 500 MG [milligram] two times a day for seizures . Review of the Fall Risk Evaluation dated [DATE], revealed Resident #319 was scored high risk for falls. Review of the Quarterly MDS dated [DATE] revealed Resident #319 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #319 required extensive assistance with two persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and hygiene), total dependence with two persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Continued review revealed Resident #319 was always incontinent of bowel and bladder. Review of Resident #319's Fall Risk Evaluation dated [DATE], revealed, Former DON #1 documented, .Reason for Assessment Request .Recent Falls .Gait Analysis .Unable to independently come to a standing position .Exhibits loss of balance while standing .Requires hands on assistance to move from place to place .Decrease in muscle coordination . Review of the care plan revealed, XXX[DATE] .at risk for falls r/t [related to] stroke XXX[DATE] .on an platelet inhibitor XXX[DATE] .communicate best with yes/no questions post-stroke XXX[DATE] .chronic pain r/t Chronic Physical Disability XXX[DATE] .contractures XXX[DATE] .require assist with activities of daily living XXX[DATE] air mattress monitor placement and function XXX[DATE] Patient to wear LLE [left lower extremity] knee extension daily as tolerated XXX[DATE] .Bed Mobility .Total Assist x [times] 2 Staff XXX[DATE] Transfers .Totally Dependent x 2 Staff (Mechanical Lift) . Continued review revealed there was no Focus/Interventions for a seizure diagnosis, no focus for risks associated with involuntary jerking motions and/or spasms during care, and no safety interventions related to use of an air mattress. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated [DATE] at 10:18 AM, revealed, .Incident Description: Resident was lying on side receiving patient care per Certified Nursing Assistant (CNA) .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed .Lower body was tense and appeared to be spasming .did not hit his head and denies pain anywhere other than his left knee .No injuries observed at time of incident .Level of Pain .5 .Mental Status .Lack of Safety Awareness .Predisposing Physiological Factors .Cognitive Impairment .Extremity Weakness-Upper .Communication Deficit .Extremity Weakness-Lower .Incontinent .Predisposing Situation Factors .History of Falls .Side Rails Up .No Witnesses found . The incident description described above was incorrect. There were two witnesses present in the room at the time of the fall. Review of the facility eINTERACT Transfer Form, dated [DATE] at 4:47 PM revealed, Resident #319 was sent to Hospital #2 for numbness on left side of head. Resident Representative (Family Member-FM #14) and Medical Director (MD) were notified. Former DON #1 completed the transfer form and Licensed Practical Nurse (LPN) #36 called report to Hospital #2 at 4:34 PM. There was no documentation on the transfer form related to Resident #319's fall on [DATE]. Review of Hospital #2's Emergency Department (ED) Records for Resident #319 dated [DATE] revealed, .CHIEF COMPLAINT .came by ems [Emergency Medical Services] from snf [Skilled Nursing Facility #1] for numbness on the top of his head for 3 days .possible stroke .HISTORY OF PRESENT ILLNESS .He states that yesterday, he was pushed off of his bed by a CNA. He hurt his left hip, low back, and hit his head .XR [Xray] Hip 2 or 3 Views Left with Pelvis .IMPRESSION: Comminuted [bone broken into more than two pieces] fracture LEFT femoral neck extending to the lesser trochanter [left hip fracture] .Impressions the patient has a left femoral neck fracture from his fall . Review of the employee record for CNA #6 revealed no documented training for Activities of Daily Living (ADL) Care. Review of a facility investigation statement dated [DATE] revealed, .Interview with [Named Resident #319]: Admin [Administrator] and Social Services asked [Resident #319] to recall the incident he had spoken to [FM-Family Member #14] about. He [Resident #319] recounted that the day prior he was sitting upright on the side of his bed when a tech came in and pushed him from behind off the side of the bed and he fell to the floor. Patient [Resident #319] could not recall why the tech was in his room but stated that he felt like it was an intentional act .[Resident #319] was asked to show how this incident occurred. Social Services [SSD #1] turned her back to [Resident #319] and [Resident #319] placed both of his hands in a cupping motion underneath Social Service's armpits and made a pushing motion away from [Resident #319]'s body . Resident #319 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #319 had hemiparesis to his left extremities and his left hand was contracted. The two witnesses in the room at the time of incident, reported conflicting accounts related to the fall. The facility provided no documentation to substantiate the details provided in the above facility investigation statement. Review of a facility investigation statement dated [DATE] revealed, .Interview .Admin [Administrator] and Social Services spoke to [Named Resident #47] concerning the incident .[Resident #47] said that he had witnessed his roommate fall to the floor with the staff member .He relayed that no pushing happened and that the lady was changing him and he fell . Review of a facility investigation statement dated [DATE] revealed, .[CNA #6] was asked by Admin and Social Services to recall the incident from yesterday .She stated that she was performing patient care to [Named Resident #319] .She said that [Resident #319] was lying horizontal on his side on the bed when she was attempting to wipe [Resident #319] .She stated that [Resident #319] had jumped a little bit, enough to cause [Resident #319]'s legs to swing out of the bed. She said that she could see that [Resident #319] was going to fall off the bed so she put her arms underneath his and assisted him to the floor. During an interview on [DATE] at 4:05 PM, FM #14 (Resident #319's significant other) stated, .[Named Resident #319] can't walk or sit up .[SNF #1] called me and said [Resident #319] fell . They said the CNA caught him .I asked his roommate [Resident #47] if [Resident #319] had hit the floor and [Resident #47] said 'yes he did' .I asked [SNF #1] if [Resident #319] had any broken bones and did they do X-rays .[SNF #1] said 'no' .I went to see [Resident #319] the next day and he was crying because he was in so much pain .I called the paramedic to take him to [Hospital #2] ER .[Resident #319] had a broken hip .[Hospital #2] did surgery on his hip the next day . During an interview on [DATE] at 3:35 PM, Former DON #1 stated she went to Resident #319's room and completed a head-to-toe assessment when notified about the fall on [DATE]. Former DON #1 stated, .When I entered the room, [Resident #319] was in a sitting position or maybe propped up against something .[Resident #319] rated his pain 5 of 10 his left knee hurt but that was his bad knee. [Resident #319] told me to just put him back in bed . When asked if Resident #319 was provided an intervention for pain rated 5 of 10, Former DON #1 replied, .[Resident #319] refused pain medication for pain in his knee and just wanted to be put back in bed . Former DON #1 stated CNA #6 and LPN #4 were in the room and used a mechanical lift to place Resident #319 back in the bed. Former DON #1 stated CNA #6 was performing incontinence care after Resident #319 had an incontinent episode when Resident #319 slid off the bed. When asked which way CNA #6 had Resident #319 turned for incontinence care, Former DON #1 replied, [Resident #319] was turned away from [CNA #6] and when [Resident #319] started to fall, I guess [CNA #6] came around to catch him. Former DON #1 stated the CNAs are able to look at the Kardex for information involving residents' care plans. Former DON #1 was asked if nursing had documented Resident #319's continuing assessment for changes post fall in the progress notes for Resident #319. She responded No. During interview with LPN #4 and CNA #6, they both denied Former DON #1 was present in the room after Resident #319's fall. LPN #4 and CNA #6 stated no lift was used to place Resident #319 back in bed. During an interview on [DATE] at 10:17 AM, CNA #16 stated Resident #319 was incontinent and required a 2 person assist with a lift for transfers. CNA #16 stated, [Named Resident #319] would push back against you when he was rolled over and that's why I always used 2 people for his care, because it was safer. During an interview on [DATE] at 2:00 PM, the Rehab Director was asked what was included in assessment for bed mobility. He responded bed mobility had a wide range which included side to side and sit to supine. The Rehab Director stated when a patient/resident is coded for 2-person assist for bed mobility, it would require a 2-person assist for incontinence care provided in bed. During a telephone interview on [DATE] at 9:05 AM, LPN #4 stated she was Resident #319's nurse on [DATE]. LPN #4 stated, .I was notified by [CNA #6] that [Named Resident #319] had fallen off the bed .the tech [CNA #6] stated [Resident #319] was turned on his side .His body tensed up and he threw his body onto the floor .This is not the first time he had the jerking movements during care .[Resident #319] said I don't know why I do this .LPN #4 stated, When I walked in the room, he was lying on the floor .It took several of us to get him up . LPN #4 was asked, did she assess Resident #319 on the floor. She responded, He had on a gown. I did not see any deformities. I tried to do what I could of a head-to-toe assessment while he was on the floor. When asked if a lift was used to put Resident #319 back in bed. LPN #4 replied, No, three of us picked him up and placed him back in bed. LPN #4 stated the DON #1 did not come to the room after the fall and complete an assessment. LPN #4 was asked if she had been trained on providing patient care on an air mattress. LPN #4 replied, No. LPN #4 was asked if Resident #319 required seizure precautions. She responded, I don't think so. LPN #4 was asked was Resident #319 care planned for jerking movements. LPN #4 replied, Yes, keep bed in lowest position. LPN #4 stated [CNA #6] should have requested help when Named Resident #319] clinched [stiffened] up. LPN #4 was asked if there had been 2 CNAs providing incontinence care for Resident #319, would that have prevented the fall. LPN #4 replied, Yes. The facility was unable to provide documentation of any assessments performed related to Resident #319's fall on [DATE]. During a telephone interview on [DATE] at 11:02 AM, CNA #6 stated, .I was giving patient care .[Named Resident #319] was turned away from me .He jumped when I was cleaning his bottom .He has jumped before related to pain .I reached back to get some cream with one hand and kept the other hand on [Resident #319] and that's when he fell .[Resident #319] stiffened up and threw his legs off the bed .I jumped across the bed and grabbed him under his arms and lowered him to the floor .[Resident #319] had jerking movements during care, that wasn't unusual. CNA #6 was asked if she had another CNA [2-person assist] with her while performing incontinence care on Resident #319, would that have prevented Resident #319 from falling out of the bed. CNA #6 replied, Yes, two people could have stopped him from falling .His care plan said 1 person assist . CNA #6 was asked if she was one of the three people that picked Resident #319 off the floor. CNA #6 responded, Yes, we did pick him up and he was groaning from pain. During an interview on [DATE] at 11:16 AM, FM #14 stated, .[Resident #319] is paralyzed on the left side. FM #14 was asked if she had Resident #319 sent out to the hospital for symptoms of a stroke. FM #14 responded, .No, When I walked in that room, he started crying .He was in so much pain .I asked them then, are y'all going to send him out for Xrays .The nurse said he doesn't have any broken bones .That's when I demanded [Resident #319] to be sent to the ER .He had not had another stroke, he had a broken hip .I talked to his roommate and [Resident #47] was in his right mind .[Resident #47] said [Resident #319] hit the floor .they [SNF #1] said he never hit the floor . During a telephone interview on [DATE] at 4:15 PM, Former SSD #1 stated, .I asked [Resident #319] to demonstrate how the CNA lowered him to the floor .I backed up to the bed and [Resident #319] extended his arms and reached under my arms like he was catching me . During an interview on [DATE] at 12:45 PM, Former DON #1 stated the Interdisciplinary Team (IDT) investigated Resident #319's fall on [DATE] and determined the air mattress on his bed had contributed to him sliding off the bed due to him moving around and an air mattress being slick. Former DON #1 stated residents on an air mattress should have a care plan with interventions in place. When asked what type of interventions would need to be implemented. Former DON #1 replied, .check placement and functioning, and do not use fitted sheets . When asked what is meant by placement and functioning of an air mattress, Former DON #1 replied, Placement is making sure the resident actually has the air mattress, the resident could have moved rooms and the mattress did not follow .Functioning means is the air mattress turned on, is it inflated. When asked if sheets should be used on an air mattress. Former DON #1 replied, No, fitted sheets would prevent the mattress from properly inflating and could possibly turn off the CPR [Cardiopulmonary Resuscitation] function [This function allows for an instant deflation providing a hard surface needed for chest compressions and intubation]. Former DON #1 stated she could not think of any safety interventions that would need to be implemented for use of an air mattress. Former DON #1 was asked if Resident #319 had seizure precautions in place. Former DON #1 stated she was not aware of Resident #319 having a diagnosis for seizures. Former DON #1 stated she would expect his care plan to reflect a diagnosis for seizures with interventions implemented. During an interview on [DATE] at 10:40 AM, the MDS Coordinator was asked to review Resident #319's quarterly assessment dated [DATE]. The MDS Coordinator was asked how she determined Resident #319 required extensive assistance of 2 persons for bed mobility, total dependence for toileting one person assist, and extensive assist of 2 persons for personal hygiene. The MDS Coordinator stated, .I would review the staffing documentation and make visual observations. If I code a resident as total assistance, then the CNA documentation must say the resident required total assistance all the time during the 7 day look back period . The MDS Coordinator was asked how Resident #319 could require 2 person assist for personal hygiene and only require 1 person assist for toileting. The MDS Coordinator stated, .I am not the CNA that cared for him so I can't tell you that . The MDS Coordinator was asked if the CNA documentation was always correct. The MDS Coordinator stated, No. During an interview on [DATE] at 2:50 PM, The MDS Coordinator was asked if seizures were checked on Resident #319's Care Area Assessment (CAA) and Resident #319 was on seizure medication twice a day, should Resident #319 have been care planned for seizures. The MDS Coordinator responded, .Seizures should have been care planned since he was on seizure medication . The MDS Coordinator was then asked if a resident was on an air mattress, should safety measures be care planned. The MDS Coordinator stated, .I don't usually put safety measures in for an air mattress . During an interview on [DATE] at 12:13 PM, Nurse Practitioner (NP) #3 stated she had no record that she or any other of the NP's at the facility had assessed Resident #319 after the fall on [DATE]. The facility's failure to provide a safe environment during care resulted in actual harm when Resident #319 fell from bed and sustained a left hip fracture on [DATE] while receiving incontinence care with use of 1 person assist.

Based on facility policy review, grievance log review, medical record review, observation and interview, the facility failed to provide good grooming, incontinence care, timely call light response, and personal hygiene for 6 (Resident #4, Resident #56, Resident #81, Resident #220, Resident #221, and Resident #368) of 22 sampled residents that required assistance with personal care. The findings include: Review of the facility policy titled, .Answering the Call Light dated 5/19/2023, revealed, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .Answer the resident call system immediately .If the resident needs assistance, indicate the approximate time it will take for you to respond .If the resident's request is something you can fulfill, complete the task within five minutes .If you are uncertain as to whether or not a request can be fulfilled .ask the nurse supervisor for assistance . Review of the facility policy titled, .Bathing dated 11/28/2017 revealed, .It is the policy of the facility to make every effort to respond to the residents' requests and needs. The facility's goal is to assist the resident with maintaining as much independence as possible with their Activities of Daily Living [ADL] but providing assistance where needed and in the bathing process. It is the policy of this facility to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin during the bathing process .The facility will offer the residents baths or showers at least two (2) times each week, or more often if requested by the resident .The manner of bathing and schedule of bathing may be adjusted per resident preference and choice of care .Residents have the right to assist in determining their care, including refusal of care .resident Care Plans .updated accordingly . Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date of April 2021, revealed, .Resident have the right to be free from abuse, neglect .prevention program consists of a facility-wide commitment and resource allocation to support the following objectives .Protect residents from abuse, neglect .by anyone including, but not necessarily limited to .facility staff .staff from other agencies .Develop and implement policies and protocols to prevent and identify .abuse or mistreatment of residents .neglect of residents .Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems . Review of the facility policy titled, .Charting/Documentation,dated 10/19/2022 revealed, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .Documentation in the medical record may be electronic, manual or a combination .The following information is to be documented in the resident medical record .Treatments of services performed .Documentation in the medical record will be objective .complete, and accurate .Documentation of procedure and treatments will include care-specific details, including .a. the date and time the procedure/treatment was provided b. the name and title of the individual(s) who provided the care .d. how the resident tolerated the procedure/treatment e. whether the resident refused the procedure/treatment f. notification of family, physician or other staff, if indicated . Review of the facility policy titled, ADL Support, dated 5/19/2023 revealed, .Resident will be provided with care, treatment and services as appropriate to maintain or improving their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .the resident and or representative has been informed of the risk and benefits of the proposed care or treatment .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident .including appropriate support and assistance with .hygiene [bathing, dressing, grooming, and oral care] .4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate . Review of the facility policy titled, ResidentRights [Resident Rights], dated 5/19/2023 revealed, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .a dignified existence .be treated with respect, kindness, and dignity .be free from abuse, neglect .self-determination .exercise his or her rights as a resident of the facility .be supported by the facility in exercising his or her rights .be informed about his or her rights and responsibilities .voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal .have the facility respond to his or her grievances . Review of the facility grievance logs from 2/23/2023 to 8/31/2023 and 10/1/2023 to 11/15/2023 revealed 19 resident complaints regarding slow response for call light, incontinence care not being timely, no bath in a week, and concerns related to showers. There was no grievance noted in the month of 9/2023. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant side, Essential Hypertension, and Contracture, Right hand. Review of the comprehensive care plan dated 11/6/2020 revealed, .Focus .I have bladder incontinence r/t [related to] Impaired Mobility .Interventions/Tasks .Check me approx [approximately] q [every] 2 hrs [ hours] and as required for incontinence. Wash, rinse and dry perineum .Focus .I have bowel Incontinence r/t immobility .Interventions/Tasks .Check resident every two hours and assist with toileting as needed .Focus .I need assist with activities of daily living .Interventions/Tasks .Encourage resident to participate .Encourage resident to use call bell system for assistance .Shower/bathe .Substantial/maximal assistance x 1 staff .Toilet transfer .Substantial/maximal assistance x 1 staff . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #4 required substantial/maximal assist with toileting, toilet transfer, and shower/bathe. Review of the electronic charting system titled [Skilled Nursing Facility SNF #1] Follow Up Question Report revealed, Resident #4 received 9 showers and 23 sponge/bedbaths from 12/1/2023 to 1/30/2024 (61 days) During an interview on 1/30/2024 at 8:30 AM, Resident #4 was asked about care at the facility. Resident #4 stated, .it depends on the CNA [Certified Nursing Assistant] you have assigned to you .some just totally ignore you .I have laid wet for 4 hours .the staff will come in turn the call light off say they will be back, and you lay and wait .a shower what is that .two 'C' words missing here at this facility, care and compassion .don't know the meaning of the words .I hate this place .don't have nothing good to say about the place . Resident #4 was asked how she tracked the time when call lights were not answered or being soiled for hours. Resident #4 pulled a clock from her overbed table and pointed at it and stated, .This is how I know . Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, Osteomyelitis, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD) and Encounter for Palliative Care. Review of the comprehensive care plan dated 3/7/2023 revealed, .Focus Resident requires assist with activities of daily living .Interventions/Tasks .Roll left and right .Substantial/maximal assistance X 1 staff .Shower/Bathe self .Substantial/maximal assistance x 1 staff .Toileting hygiene .Substantial/maximal assistance required x 1 staff .Focus The resident has .incontinence r/t [related to] in mobility following CVA [Cerebral Vascular Accident] and amputation .Interventions/Tasks .Check the resident upon report of need to toilet or has toileted and as required for incontinence .Focus .The resident has bowel incontinence r/t .CVA and impaired mobility .Interventions/Tasks .Check resident every two hours and assist with toileting as needed . Review of the Quarterly MDS dated [DATE] revealed Resident #56 had a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #56 was dependent for toileting, personal hygiene, and bathing which required extensive assistance of one person. Review of the electronic charting system titled [SNF #1] Follow Up Question Report revealed, Resident #56 received 2 showers and 19 sponge/bedbaths from 11/6/2023 to 1/4/2024 (59 days). During an observation and interview on 12/19/2023 at 12:55 PM, Resident #56 was in the bed. Resident #56's fingernails were long and dirty. Resident #56 was asked when he had received a shower. Resident #56 stated, .I couldn't tell you the last time I received a shower .they may take a wipe and wash me that way but no shower .the staff always has an excuse .I have complained .doesn't really do any good .I like to be clean shaven .my family comes in to shave me .I am often wet, and I will have to wait hours .staff will come in answer the light and say they will be back, and I never see them again. I have called my family at times because I was wet . During an observation and interview on 1/5/2024 at 10:30 AM, Resident #56 was in bed and continued to have long dirty fingernails, a mustache and beard. During an interview on 1/23/2023 at 10:15 AM, The Interim Director of Nursing (IDON) was asked when (Named Resident #56)'s shower was scheduled. The IDON stated, Monday and Thursday on 7PM-7AM shift 2 times a week. The IDON was asked to review the electronic charting system sheet named Follow Up Question Report for bathing/shower dated 11/6/2023-1/5/2024. The IDON confirmed only 2 showers were documented from 11/6/2023-1/5/2024 on 12/7/2023 and 12/21/2023. The IDON stated, The CNAs do paper documentation for showers sometimes. The IDON was asked should the electronic charting where CNAs chart, match the shower sheets and the IDON stated, yes, they should match. During an interview on 1/24/2024 at 2:58 PM, Family Member (FM) #31 stated, .It has been 3 weeks at a time that [Named Resident #56] goes without a shower .I come in about every 2 weeks to shave him and cut his hair because they don't shave him .I have been at the facility when he would be soiled, and he waited 3 hours to be changed .I have talked to the Administrator several times .it's been at least 2 weeks since he has been out of the bed .I filed a complaint with the state about his care . During an interview on 1/30/2024 at 3:38 PM, the Administrator was asked if he recalled FM #31 filing a grievance in relation to [Named Resident #56]'s care. The Administrator provided a grievance dated 11/4/2023 which revealed, COMPLAINT .CNA .was very rushed and did not change him gently. He said his head was up against the siderail. She had a sour attitude with him .INVESTIGATION STEPS AND FINDINGS: Employee was immediately re-assigned for additional oversight and coaching and she left the facility and self-terminated .FINAL DISPOSITION AND CORRECTIVE ACTION: Employee was coached and opted to resign .The grievance form was signed by Resident #53. The Administrator stated, .this is all I could find related to grievance from the resident . Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare following surgical amputation, Type 2 Diabetes Mellitus, and Congestive Heart Failure. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #81 was dependent for toileting, supervision related to personal hygiene, and substantial/maximum assistance with rolling left and right, sit to lying, and lying to sitting on side of bed. Review of the comprehensive care plan dated 11/24/2023 for Resident #81 revealed, Focus Resident requires assist with activities of daily living Date inititiated: 05/11/2023 .Interventions/Tasks .Toileting hygiene .Dependent x 1 staff .Tub/Shower .Dependent x 2 staff .Focus Abuse/Neglect: I'm at risk for actual/potential abuse/neglect related to my dependence on others for ADL [Activities of Daily Living] care .Goal I will not experience any form of abuse or neglect through review date .Interventions/Tasks Provide assistance with ADL's as needed .Provide support and ensure resident is free from abuse and/or neglect .Focus Trauma Informed Care/Stressful Life Experience .I may have trauma related stress related to loss of independence and living in a nursing facility .Goal I will verbalize a sense of control and safety .Interventions/Tasks Actively listen to resident as they describe life stresses .Encourage verbalization of feelings, perceptions, and fears .Identify and avoid triggers for stresses . Further review of the comprehensive care plan dated 12/1/2023 revealed, Focus The resident has mixed bladder incontinence .Interventions/Tasks .Check the resident (FREQ) [Frequently] and as required for incontinence .Focus The resident has bowel incontinence r/t immobility .Interventions/Tasks .Provide pericare after each incontinent episode . Review of the electronic charting system titled [SNF #1] Follow Up Question Report revealed, Resident #81 received 0 showers and 20 sponge/bedbaths from 11/6/2023 to 1/4/2024 (59 days) During an observation and interview on 12/19/2023 at 12:20 PM, Resident #81 was noted to have dry flaky skin to his scalp, his hair looks oily, and unkempt. Resident #81 had dried food on his t-shirt, his nails were dirty, and his beard had flakes, which appeared to be flaky dry skin. Resident #81 was asked when he last received a shower. Resident #81 stated, .I really can't tell you when I have had a shower .the staff sponge me off a couple of times a week, but I really wouldn't call it a bath . Resident #81 had stains on his pillowcase and sheet. During an observation and interview on 1/4/2024 at 9:00 AM, Resident #81 continued to have flaky oily hair, flakes in his beard which appeared to be dry flaky skin, fingernails continued to be dirty, and resident's t-shirt was dirty. Resident #81 was asked if he had a shower or been up since 12/19/2023. Resident #81 stated, .no shower .I am supposed to get it on Monday and Thursday .I have asked to be up, but I continue to lay in the bed . During an observation and interview on 1/5/2024 at 10:15 AM, Resident #81 continued to appear disheveled, hair continued to be oily with dry flakes noted in hair and beard. Resident #81 continued to wear the same dirty t-shirt he had on 1/4/2024. Resident #81 was asked if he had received a shower. Resident #81 stated, .No shower .I received incontinence care around 9:00 AM .it doesn't do any good to ask about a shower, usually not enough staff . During an observation and interview on 1/5/2024 at 11:30 AM, Resident #81 continued to have flaky oily hair with flakes in his beard. Resident #81 had dirty fingernails and continued to have on the same dirty t-shirt he had on 1/4/2024. Resident #81 stated, .didn't get my bath .I wasn't offered one .no bed bath, no shower or nothing .my hair hasn't been washed since I went to the barber shop and got it cut .I think maybe 2 months ago .they don't take care of us . Resident #81 was asked about answering of his call light and incontinence care. Resident #81 stated, .we wait hours for our lights to be answered .sometimes the staff will ask what we need turn the light off and they never come back .it is according to who the CNA is whether you get help or lay in urine for hours .I have had to lay in feces for hours .don't do any good to complain . During an observation and interview on 1/8/2024 at 8:50 AM, Resident #81 was sitting in his wheelchair in the front lobby. Resident #81 stated, I am waiting on transportation to go to the doctor. Resident #81's hair continued to be flaky and oily. Resident #81's fingernails continued to be dirty. Resident #81 had on shorts, a dirty t-shirt and a coat. Resident #81 continued to appear unkempt. During an interview on 1/9/2024 at 2:35 PM, Licensed Practical Nurse (LPN) #18 stated, .[Named Resident #81] came back from his doctor's appointment yesterday, he was complaining at the doctor about being short of breath and we sent him to the hospital. I think the hospital said he was in fluid overload . During an interview on 1/23/2024 at 9:06 AM, Regional Nurse Consultant #1 obtained the History and Physical for Resident #81's admission to the hospital and stated, Now it says in the report he was not getting up and receiving baths but he is very non-compliant. During an interview on 1/23/2024 at 11:00 AM, the Regional Nurse Consultant #1 stated, We offer showers 2 times per week. The Regional Nurse Consultant #1 was asked to review the documentation for his showers and if she noted any refusals from 11/7/2024 to 1/4/2024. The Regional Nurse Consultant #1 stated, No. During an interview on 1/23/2024 at 11:20 AM, Certified Nursing Assistant (CNA) #22 was asked how often the residents had showers scheduled. CNA #22 stated, .The showers should be done 2 times per week. I will be honest with you the night shift doesn't follow the shower schedule or do the showers. Management just don't crack down on them . CNA #22 was asked where a CNA should chart a shower when it had been completed. CNA #22 stated, .It should be documented in the computer system . Review of Hospital #6 History and Physical form 1/8/2024 for Resident #81 noted, XXX[AGE] year old male with history of hypertension, diabetes, CAD [Coronary Artery Disease] s/p [status post] CABG [Coronary Artery Bypass Surgery] who presents from his skilled nursing facility with volume overload and dyspnea. Patient was seen in the vascular clinic earlier today for a scheduled appointment and was told to come here because of his worsening edema [swelling caused by too much fluid trapped in the body's tissues]. He reports intermittent shortness of breath at rest .He reports that they (Named Skilled Nursing Facility SNF #1) .have not given him a bath or shower in 1 to 2 months, exam is consistent with this .Discharge Planning: admitted as inpatient for acute heart failure exacerbation. Will need new skilled nursing facility placement at discharge, case management consulted . Review of the medical record revealed Resident #220 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection, Unspecified Fall, and Type 2 Diabetes Mellitus. Review of the Admission MDS dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #220 required substantial/maximal assistance with toileting and shower/bathe and supervision or assistance with personal hygiene. Further review of the MDS revealed resident was at risk for developing pressure ulcers. Review of the comprehensive care plan for Resident #220 revealed, .Focus Resident requires assist with activities of daily living .Interventions/Tasks Assist with bed mobility .toileting .and bathing as required .Encourage resident to participate to the fullest extent possible with each interaction .Encourage resident to use call bell system for assistance .Toileting hygiene .Substantial/maximal assistance required x 1 staff .Shower/bathe self .Substantial/maximal assistance x 1 staff .Toilet transfer .Supervision .required .Tub/shower transfer .Supervision .assistance required .No Male CNA for Direct Care . Review of the electronic charting system titled [SNF #1] Follow Up Question Report revealed, Resident #220 received 10 showers and 14 sponge/bedbaths from 12/1/2023 to 1/30/2024 (61 days). During an observation and interview on 1/30/2024 at 8:20 AM, Resident #220 was asked how often do you receive a shower. Resident #220 stated, .I think I have had a few showers since I have been here but usually it is just a sponge off in the bed .I believe it was a week ago when my hair was washed .I would like to take my showers instead of a bed bath . Review of the medical record revealed Resident #221 was admitted to the facility on [DATE] with diagnoses which included Unspecified Trochanteric Fracture of Left Femur, and Type 2 Diabetes Mellitus. Review of Resident #221's baseline care plan dated 1/26/2024 revealed, .Resident requires assist with activities of daily living r/t (related to) recent hospital stay .Interventions/Tasks .Assist with bed mobility, transfers, toileting, and bathing . Review of the Occupational Therapy (OT) Treatment Encounter Note dated 1/29/2024 revealed, .Precautions Details: NWB [Non Weight Bearing] (L) [Left] LE [lower extremity] . During an interview on 1/30/2024 at 1:00 PM, Resident #221 was asked about his care at the facility. Resident #221 stated, .can't get no help around here .I have broke my hip and I need help going to the bathroom. I am not suppose to bear all my weight on my left leg. I can't sit and wait and wait for someone to help me to the bathroom cause I will wet or mess on myself. I just have to go on with my walker and sometimes I have to bear my weight to get to the bathroom. The call light just goes off and you have to wait, sometimes an hour . Review of the medical record revealed Resident #368 was admitted to the facility on [DATE] with diagnoses which included Spondylopathy (disorder of the vertebrae), Pain, Dorsalgia (pain in the back), and Contracture of Muscle Left Lower leg. Review of the comprehensive care plan dated 12/14/2023 for Resident #368 revealed, .Focus Resident requires assist with activities of daily living r/t recent hospital stay .Interventions/Tasks .Assist with bed mobility, transfers, toileting, and bathing as required .Encourage resident to use call bell system for assistance .Toileting hygiene .Substantial/maximal assistance required .Shower/bathe self .Substantial/maximal assistance Tub/Shower transfer .Dependent x 2 staff .Focus The resident has a Condom catheter .Goal The resident will show no s/sx [signs/symptoms] of Urinary Infection .Interventions/Tasks .Focus The resident has pressure ulcer .Left ischium stage III .Reopened 1-24-24 .Goal The resident's .Pressure ulcer will show signs of healing and remain free from infection by/through review date . Review of the Admission MDS dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #368 required substantial/maximal assistance with toileting and shower/bathe and supervision/ assistance with personal hygiene, an external catheter and occasionally incontinent of urine and frequently incontinent of bowel, a stage 2 and stage 3 pressure ulcer present over the last 7 days. Review of the electronic charting system titled [SNF #1] Follow Up Question Report revealed, Resident #368 received 1 shower and 16 sponge/bedbaths from 12/13/2023 to 1/30/2024 (48 days). During an interview on 1/30/2024 at 1:10 PM, Resident #368 was asked how often do you receive a shower. Resident #368 stated, .No showers since I been here .I just get a bed bath .I think the last one was a month ago .you set in your feces for hours .you say anything about it they label us like troublemakers .if you keep complaining they will write you up put it in your records .CNAs will say this room is a problem .not compassionate .the staff will come in find out what you need tell you someone is coming then turn the light off .the supervisors want to be friends with the CNAs not manage them .

Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of verbal abuse and/or neglect for 3 (Resident #53, Resident #56 and Resident #81) of 22 sampled residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date of April 2021, revealed, .Residents have the right to be free from abuse, neglect .verbal .Identify and investigate all possible incidents of abuse, mistreatment .Investigate and report any allegations within timeframes required by federal requirements .Protect residents from any further harm during investigations . The facility investigation revealed on 11/29/2022 at 10:56 AM the Former Director of Nursing (DON) #1 completed an interview with (Named FM #26). (Named FM #26) reported that she visited with (Named Resident #53) and the resident told her that she hadn't gotten a shower since 11/18/2022 and that the resident was being neglected. (Named FM #26) stated she spoke to nursing staff and nursing staff promised her that (Named Resident #53) would have her shower by the end of the shift. (Named Resident #53) called (Named FM #26) that evening and stated she still had not received a shower. The (Named FM #26) then called the facility at 6:00 pm spoke to a nurse who reported the shower would be offered again. (Named FM #26) then called (Named Resident #53) and waited on the telephone until the CNA came in to offer the shower. (Named FM #26) stated the CNA (Named CNA #8) came in and very rudely offered the resident a shower but was rushing her. It was noted in the facility investigation that Resident (Named Resident #53) has history of refusals and care planned for this. (There was no documentation in Resident #53's medical record of refusal of care and no focus on the care plan related to the refusal of care) Interviews completed with all residents on the unit with Brief Interview for Mental Status (BIMS) greater than 10, revealed no concerns for physical or verbal harm. The results of the facility investigation were .not verified due to evidence and history of shower refusals and from statements collected by nursing staff . Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease, Flaccid Hemiplegia Affecting Unspecified Side, Type 2 Diabetes Mellitus, and Epilepsy. Review of the comprehensive care plan dated 5/17/2022 revealed, .Focus .Resident requires assist with activities of daily living .Interventions/Tasks .Assist with .bathing as required .Shower/bathe .Substantial/maximal assistance x 1 staff . The care plan had no focus or interventions addressing a history for refusal of care for showers/baths for the first 6 months of admission until 11/29/2022 Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Resident #53 had a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #53 required substantial/maximal assistance with shower/bathe During an interview on 12/13/2023, Resident #53 was asked about her care at the facility. Resident #53 stated, .my family did complain about my showers not getting done and the CNA was very rude that evening [11/29/2022] . The Former DON #1 was asked during her investigation did she question other residents to see if they had any concerns related to their showers. The Former DON #1 stated, .No I didn't ask the other residents . The Former DON #1 was asked did she investigate the reasons why [Named Resident #53] refused her showers. The Former DON #1 stated, .I did not try to investigate why the resident was refusing her showers . The Former DON #1 confirmed [Named Resident #53] had a history of refusing showers. The Former DON #1 was asked to review the care plan regarding (Named Resident #53) refusing care. The Former DON #1 reviewed the care plan including resolved and cancelled entries and was unable to find a focus or interventions for refusals of care. Review of the facility investigation dated 9/15/2023 revealed, .[Named Resident #81] (BIM Brief Interview for Mental Status - 15) reported to the Unit Manager that he had a confrontation with his night shift [7 PM-7AM 9/14/2024] CNA [Certified Nursing Assistant]. Resident reported that the confrontation had arisen during a periodic check around midnight by the alleged perpetrator. Resident stated that he was upset with the frequency in which the same {CNA} had made rounds to check on him. Resident stated that the CNA was very argumentative and made a threatening remark when exiting the room. Resident has displayed no signs of psychosocial distress or harm .Residents roommate [Named Resident #56 BIM-15] corroborated [Named Resident #81 BIM - 15] allegation against CNA when questioned by administration .Administrator conducted a phone interview with the alleged perpetrator, [Named CNA #11], on 9/15/2023 regarding the alleged incident. [Named CNA #11] stated that she mistakenly had thought that the Resident was independent with ADLs. [Named CNA #11] stated that when she checked on [Named Resident #81] around midnight he became very upset. [Named CNA #11] states [Named Resident #81] started cursing her out so she exited the room. [Named CNA #11] denied making any threatening statement to the Resident during the interaction .Allegation could not be verified based on conflicting statements received from the caregiver and Resident . Continued review of the facility investigation Facility investigation dated 9/15/2023 revealed a written statement completed by Unit Manager LPN #19 which stated, .Tech [CNA #11] came @ 11 - told them they were independent, told [Named Resident #81] she was brand new, he told her she still had to check them. She said 'you don't tell me what to do' 'I'll kick your ass, slamed [slammed] the bathroom door he sadi [said] '[expletive] you try it' She said '[expletive] you mother [expletive]', you can suck my ass' after confrontation .She called [Resident #56] a'mfer' [expletive] . Review of CNA #11's employee clock in and clock out for 9/14/2023 revealed the employee clocked in at 7:04 PM on 9/14/2023 and clocked out at 7:03 AM on 9/15/2023. The allegation of abuse reported by Resident #81 revealed the interaction with the employee occurred around 11:00 PM - 12:00 AM on 9/14/2023. The employee clock in and clock out revealed CNA #11 worked the remainder of the shift past the time of the allegation of the verbal abuse. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly MDS dated [DATE] revealed Resident #56 had a BIMS score of 15, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #56 was dependent for toileting, personal hygiene, and bathing which required extensive assistance of one person. During an interview on 12/19/2023 at 12:55 PM, Resident #56 stated, .[Named CNA #11] came in here about 11:00 PM [9/14/2023], my roommate asked her why she was just now checking on us. The [Named CNA #11] said she thought we could take care of ourselves. The [Named CNA #11] was standing in the bathroom, yelling, woke me up, the CNA told my roommate to suck her ass and slammed the door .I didn't trust the girl, I was afraid she would hurt us .I stayed up all night .my roommate seen her in the hall later that night .she called me a mother [expletive] .we stayed up that night because we were afraid she would come back in here . Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare following surgical amputation, Type 2 Diabetes Mellitus, Congestive Heart Failure, and Cerebral Infarction. Review of the Psychological Diagnostic Interview for Resident #81 dated 9/19/2023 revealed, .He {Resident #81] related events related to the abuse, saying that he didn't sleep the night of the event, saying he was fearful for his safety . Review of the Quarterly MDS dated [DATE] revealed Resident #81 had a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #81 was dependent for toileting, supervision related to personal hygiene, and substantial/maximum assistance with rolling left and right, sit to lying, and lying to sitting on side of bed. During an interview on 12/19/2023 at 11:34 AM with Former DON #1 and Administrator confirmed they were notified of the allegation of verbal abuse on 9/15/2023. The Former DON #1 stated, .The written statement in the investigation was the Unit Manager's [LPN #19] statement of what [Named Resident #81] reported. The Administrator was asked if [Named Resident #56, Named Resident #81's roommate] or any other employees that worked that shift were interviewed? The Administrator stated, If I had interviewed the roommate, it would be in the investigation. I didn't ask anyone else because they were not in ear shot, I would have thought the roommate would have been interviewed. I think the roommate was interviewed by the Social Service Director [SSD]. When I called [Named CNA #11] she had an attitude with me. I just had what [Named Resident #81] reported and it was conflicted with what [Named CNA #11] said happened. I was not aware [Named Resident #81] said he didn't sleep the night of the event and was fearful for his safety. The supervisor [LPN #26] for 9/14/2023 denied knowing anything about it . The Administrator failed to follow up on documented findings that resulted in an incomplete investigation. During an interview on 12/19/2023 at 12:20 PM, Resident #81 stated, .[Named CNA #11] threatened us, slammed the door, [Named CNA #2] another tech took care of me and my roommate the rest of the night. [Named CNA #11] never came in our room to check on us until 11:00 PM that night. When [named CNA #11] came in the room I said 'are you not supposed to check on us every 2 hours'. The CNA told me to shut up and threatened to kick my ass. I did tell her '[expletive] you' and then [Named CNA #11] said suck my ass, no one wants to take care of you, she slammed the door .I told the supervisor that night, I can't remember the supervisor's name, but the CNA wasn't sent home. I saw the CNA in the hallway about 12:00 AM and 1:00 AM. The night nurse was an agency nurse, she knew about what happened. I stayed up all night because I was scared, and my roommate was scared. I never seen anybody get that angry, they should have sent her home. I am pretty sure she worked all night. The supervisor on night shift didn't do anything. [Named CNA #11] called my roommate a 'mother [expletive]' . During an interview on 12/19/2023 at 2:17 PM, the SSD reviewed LPN #19's written statement. (the written statement was included in the facility investigation) The SSD stated, .[Named Resident #81 and Named Resident #56] pretty much said the same thing. The CNA was mean and used derogatory language and told [Named Resident #81] I'll kick your ass .I do feel this was verbal abuse .[Named Resident #56] confirmed what happened .Resident interviews are usually what I take care of in an investigation . During an interview on 1/4/2024 at 9:00 AM, (Named Resident #81) was asked when the incident occurred on 9/14/2023 how did it make him feel? (Named Resident #81) stated, .it made me angry; it made me sad because she said nobody wants to take care of me, I was dirty .needed to be changed .I told [Named CNA #27] about it .I felt apprehensive [anxious or fearful that something bad or unpleasant will happen] .scared she [CNA #11] would hit me in my sleep .we [Resident #81 and Resident #56] talked to the supervisor and the nurse .the supervisor asked me if I wanted the CNA back in here .I told her no .I told them exactly what she said to me .and my roommate heard it because she woke him up . During an interview on 1/4/2024 at 4:20 PM, LPN #18 stated, .The residents [Resident #81 and Resident #56] told me about the incident that happened the night before on 9/14/2023 .It was [Named LPN #19] I reported it to that morning .I don't remember who the nurse was that morning from night shift. The Administrator never questioned me about the incident . LPN #18 confirmed the written statement from LPN #19 was what the two residents told her as to what happened on 9/14/2023. During an interview on 1/5/2024 at 11:00 AM, the Administrator stated, .I don't see an interview with [Named LPN #21] that worked night shift [9/14/2023] .when I interviewed the CNA, judging the way she talked to me she didn't fit the model of the type of employee I felt the facility needed .It does matter to me that 2 alert residents voiced concerns about the way she talked to them .It would have been important to talk to that nurse .I came in late that day and done what I felt I needed to do .a resident should not be fearful of course not .knowing what I know today .I would have substantiated verbal abuse .I would expect my staff to intervene immediately with any abuse .and remove the employee until investigation was completed . The Administrator failed to conduct a thorough investigation and did not take immediate action to mitigate the risk of psychosocial harm (fear and anxiety) for all residents. During a telephone interview on 1/5/2024 at 11:20 AM, LPN #19's written statement was read to LPN #19. She stated, .yes that is my statement .I was the supervisor on 9/15/2023 .[LPN #18] reported this incident to me and I went down to speak to [Named Resident #81] .I also alerted the SSD and Former DON #1 .the Administrator was also aware .the night shift nurse didn't say anything to me about the incident . During a telephone interview on 1/8/2024 at 12:10 PM, LPN #26 was asked if she was the supervisor on 9/14/2023. LPN #26 confirmed she was the supervisor. This surveyor read the statement from the facility's investigation, .Supervisor [LPN #26] in facility at time of alleged incident, had no knowledge of [Named CNA #11] cussing at resident . LPN #26 was asked if that was an accurate statement. LPN #26 stated, .absolutely not .I was notified by the tech [CNA #27] that night . During an interview on 1/8/2024 at 12:30 PM, Former DON #1 stated, .LPN #26 didn't know anything about anyone cussing the resident .[Named CNA #11] thought [Named Resident #81] was independent .[Named LPN #26] said something about switching [Named CNA #11] out but I thought it was the resident didn't want the CNA back in his room .I am not sure why the CNA was placed on another hall .

Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to report to the state agency allegations of verbal abuse and neglect within 2 hours of the incident for 3 (Resident #53, Resident #56, and Resident #81) of 22 sampled residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date of April 2021, revealed, .Residents have the right to be free from abuse, neglect .This includes .verbal, mental .Protect residents from abuse, neglect .by anyone including, but not necessarily limited to .facility staff .staff from other agencies .implement policies and protocols to prevent and identify .abuse or mistreatment of residents .neglect of residents .Provide staff orientation and training/orientation programs that include topics .identification and reporting of abuse .Identify and investigate all possible incidents of abuse, mistreatment .Investigate and report any allegations within timeframes required by federal requirements .Protect residents from any further harm during investigations . Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease, Flaccid Hemiplegia Affecting Unspecified Side, Type 2 Diabetes Mellitus, and Epilepsy. Review of Resident #53's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #53 required substantial/maximal assistance with shower/bathe and setup of clean-up assistance with personal hygiene. Review of the comprehensive care plan dated 5/17/2022 revealed, .Focus .Resident requires assist with activities of daily living [ADL] .Interventions/Tasks .Assist with bed mobility, transfers, and bathing as required .Personal hygiene .Set up or clean up assistance required .Shower/bathe .Substantial/maximal assistance x 1 staff .Tub/Shower transfer .Dependent x 1 staff .Focus .The resident is at risk for actual/potential abuse/neglect r/t [related to] dependence on others for ADL care . Review of the facility investigation revealed, (Named Family Member [FM] #26) reported by telephone to nursing staff on 11/28/2022 at 6:00 PM felt (Named Resident #53) was being neglected. Continued review of the facility reported investigation revealed (FM #26) alleged she overheard verbal abuse over (Named Resident #53)'s cell phone. The neglect/verbal abuse was not reported to the State Agency (SA) until 11/29/2022 at 12:02 PM (18 hours and 2 minutes later). During an interview on 12/13/2023, Resident #53 was asked about her care at the facility. Resident #53 stated, .my family did complain about my showers not getting done and the CNA was very rude that evening . Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, Osteomyelitis, Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly MDS dated [DATE] revealed Resident #56 had a BIMS score of 15 which indicated no cognitive impairment. During an interview on 12/19/2023 at 12:55 PM, Resident #56 stated, .[Named CNA #11] came in here about 11:00 PM (9/14/2023), my roommate asked her why she was just now checking on us .the [Named CNA #11] was standing in the bathroom, yelling, woke me up, the CNA told my roommate to suck her ass and slammed the door. Resident #56 stated, .I didn't trust the girl, I was afraid she would hurt us .I stayed up all night . The CNA never came back in our room, but my roommate seen her in the hall later that night. Resident #56 further stated, she called me a mother [expletive], I don't know why .we stayed up that night because we were afraid she would come back in here . Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Aftercare following surgical amputation, Type 2 Diabetes Mellitus, and Congestive Heart Failure. Review of the Quarterly MDS dated [DATE] revealed Resident #81 had a BIMS score of 15 which indicated no cognitive impairment. Review of the facility reported investigation dated 9/15/2023 revealed, .administrator was notified of the incident .09/15/2023 2:35 PM .Date and time when the alleged incident occurred 09/14/2023 11:00 PM .[Named Resident #81] (BIM Brief Interview for Mental Status - 15) reported to the Unit Manager that he had confrontation with his night shift [7 PM-7AM 9/14/2024] CNA. Review of the facility investigation revealed the allegation of abuse occurred on 9/14/2023 around 11:00 PM - 12:00 AM and was not reported to the Administrator until 9/15/2023 at 2:35 PM. The verbal abuse was not reported to the SA until 9/15/2023 at 2:41 PM (15 hours and 21 minutes later). During an interview on 12/19/2023 at 11:34 AM, the Former DON #1 and Administrator confirmed they were notified of the allegation of verbal abuse on 9/15/2023. The Administrator was asked if [Named Resident #56, Named Resident #81's roommate] or any other employees that worked that shift were interviewed.The supervisor [LPN #26] for 9/14/2023 denied knowing anything about it . During an interview on 12/19/2023 at 12:20 PM, Resident #81 stated, .[Named CNA #11] never came in our room to check on us until 11:00 PM that night [9/14/2023] .I told the supervisor that night .the night nurse was an agency nurse, she knew about what happened . During an interview on 12/19/2023 at 2:17 PM, SSD reviewed LPN #19's written statement. (the written statement was included in the facility investigation) SSD stated, .[Named Resident #81 and Named Resident #56] pretty much said the same thing. The CNA was mean and used derogatory language and told [Named Resident #81] I'll kick your ass .I do feel this was verbal abuse .the Administrator usually notifies me about potential abuse so I can interview the residents .[Named Resident #56] confirmed what happened .I would have told the Administrator .I don't know why the nurse didn't report it that night .Resident interviews are usually what I take care of in an investigation . During a telephone interview on 12/19/2023 at 8:27 PM, LPN #21 stated, .I worked 9/14/2023 .I do remember that Caucasian resident [Named Resident #81] asked to speak to the nurse .I was trying to defuse the situation .I know the CNA was changed out and placed on another assignment .I don't remember the roommate saying anything .I told the nursing supervisor .I don't remember her name .and it was passed on to the day shift nurse .I don't remember the CNA that took care of the residents after this happened .the Administrator never asked me about it, you are the 1st person that has called me . During an interview on 1/4/2024 at 9:00 AM, (Named Resident #81) was asked when the incident occurred on 9/14/2023 how did it make him feel? (Named Resident #81) stated, .it made me angry; it made me sad because she said nobody wants to take care of me, I was dirty .needed to be changed .I told [Named CNA #27] about it .I felt apprehensive [anxious or fearful that something bad or unpleasant will happen] .scared she [CNA #11] would hit me in my sleep .we [Resident #81 and Resident #56] talked to supervisor and nurse .the supervisor asked me if I wanted the CNA back in here .I told her no .I told them exactly what she said to me .and my roommate heard it because she woke him up . During a telephone interview on 1/8/2024 at 12:10 PM, LPN #26 was asked if she was the supervisor on 9/14/2023. LPN #26 confirmed she was the supervisor. This surveyor read the statement from the facility's investigation, .Supervisor [LPN #26] in facility at time of alleged incident, had no knowledge of [Named CNA #11] cussing at resident . LPN #26 was asked if that was an accurate statement. LPN #26 stated, .absolutely not .I was notified by the tech [CNA #27] that night .I called him [Named Administrator] from my personal phone that night [9/14/2023] but he didn't answer. I told [Named CNA #27] to take care of [Resident #81 and Resident #56] the rest of the night .the next day the Administrator called me on a 3-way call, I am not sure who was on the call but there were other people besides the Administrator . During an interview on 1/10/2024 at 4:25 PM, Former DON #1 was asked when should an allegation of resident abuse be reported. The Former DON #1 stated within 2 hours. The Former DON #1 confirmed the allegation of resident abuse was not reported until the next day.

Based on facility policy review, facility eINTERACT Transfer Form review, medical record review, and interview, the facility failed to communicate appropriate information to the receiving facility and ensure an effective transition of care for 1 of 1 (Resident #319) sampled residents reviewed. Resident #319 was transferred to Hospital #2 Emergency Department (ED) on 5/27/2022 for evaluation of neurological symptoms. Facility nursing staff failed to communicate information related to Resident #319's 5/26/2022 fall during both oral and written reports to Hospital #2. The findings include: Review of the facility's policy titled Transfer and Discharge Procedures, dated 12/2017 revealed, .Transfer and discharge procedures must provide sufficient preparation and orientation of the resident to ensure a safe, orderly transfer or discharge from the facility . Facility was unable to provide the policy titled Transfer and Discharge Procedures dated 2022. Review of the facility's policy titled Transfer or Discharge, Facility Initiated, dated 3/8/2023, revealed, .Should a resident be transferred or discharges for any reason, the following information is communicated to the receiving facility or provider .g) All other information necessary to meet the resident's needs .any other documentation, as applicable, to ensure a safe and effective transition of care . Review of the medical record revealed Resident #319 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Speech and Language Deficits following Cerebrovascular Disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #319 revealed, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of the facility document (event/incident report) titled, Fall: Witnessed, dated 5/26/2022 at 10:18 AM, revealed, .Incident Description: Resident was lying on side receiving patient care per Certified Nursing Assistant (CNA) .to remove fecal matter .Resident grunted and moved his body like he was in pain and forcefully projected himself off of bed. Lower body was tense and appeared to be spasming . Review of the facility eINTERACT (facility document tool) Transfer Form dated 5/27/2022 at 4:47 PM revealed, Resident #319 was sent to Hospital #2 for numbness on left side of head. The Former Director of Nursing (DON) #1 completed the transfer form and Licensed Pratical Nurse (LPN) #36 called report to Hospital #2 at 4:34 PM. There was no documentation related to Resident #319's fall on 5/26/2022. Review of Resident #319's progress notes dated 5/27/2022 at 4:47 PM, revealed, .pt [patient] sent out due to family request. Pt c/o [complained of] numbness on left side of head . During a telephone interview on 2/1/2024 at 3:34 PM, LPN #36 stated, .I always assisted the nurse during a transfer by calling report to the receiving facility .I used the Interact transfer form as a guide when calling report, and sent a copy of the form with the resident to the emergency room [ER] . The surveyor asked LPN #36 if information related to a fall the previous day should have been included in the report to the receiving facility. LPN #36 replied, Yes. LPN #36 stated if he had known about Resident #319's fall on 5/26/2022, he would have included it on the transfer form and in the call for report. LPN #36 stated if the information about the fall was not noted on the transfer form for Resident #319, then he was unaware of the fall. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility failed to ensure Hospital #2 received accurate and appropriate information related to Resident #319's fall that could have likely resulted in a delay of treatment in the ER.

Based on facility policy review, medical record review, observation, and interview, the facility failed to treat 1 (Resident #88) of 22 sampled residents reviewed for resident rights with respect, dignity, and care in a manner and in an environment that promotes maintenance and enhancement of her quality of life. The findings include: Review off the policy titled, Door Safety System, dated 2/2023 revealed, .It is the policy of this facility to provide guidelines on utilizing and maintaining an Electronic Detection System to promote the safety of residents At-Risk for elopement .1. Resident Evaluation A. Resident are evaluated for Risk of Elopement on admission, readmission, quarterly, and as needed. B. Residents identified At-Risk for Elopement will be further evaluated for appropriate interventions, which may include use of an individual WanderGuard Tag Device [bracelet a resident wears with the sensors that when an at-risk wanderer gets close to a monitored door it will sound to alert staff] .D. Resident Care Plan will be updated accordingly. E. Individual WanderGuard Tag devices, when placed on a resident, will be activated using the hand-held WanderGuard Blue Detector. F. Individual WanderGuard Tag devices will be checked daily by Nursing to ensure they are functioning appropriately . Review of the facility policy titled, Wandering and Elopements, dated 5/19/2023 revealed, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner .get help from other staff members to inform the immediate vicinity .instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises . Review of the facility policy titled, ResidentRights [Resident Rights], dated 5/19/2023 revealed, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .a dignified existence .be treated with respect, kindness, and dignity .be free from abuse, neglect .self-determination .exercise his or her rights as a resident of the facility .be supported by the facility in exercising his or her rights .be informed about his or her rights and responsibilities .voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal .have the facility respond to his or her grievances . Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease, Cirrhosis of the Liver, and Depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of comprehensive care plan dated 12/20/2022 revealed Resident #88 was independent for all activities of daily living (ADL). Continue review of the comprehensive care plan revealed, .Resident prefers to plan own day .The resident has the potential for a mood d/o [disorder] related to: diagnosis of depression and placement in a Skilled Nursing Facility .Monitor/record/report to MD prn [as needed] .sadness, loss of pleasure and interest in activities . depression, anxiety, sad mood as per facility behavior monitoring protocols . Review of the Progress Notes for Resident #88 revealed, .12/30/2023 20:04 (8:04 PM) Nursing Progress Note .Wander guard placed on her Right ankle Review of Resident #88's Progress Notes from 12/3/2023 through 12/30/2023 revealed no documentation of wandering, confusion, delirium, or exit seeking behavior. Observation and interview on 1/3/2024 at 9:45 AM revealed, Resident #88 was in the bed with call light in reach. Resident #88 was asked how she was doing? Resident #88 stated, .I am not doing good today .I am mad .I feel like I am in a Jail . Resident #88 was asked why she felt this way? Resident #88 stated, .this ankle bracelet I can't even go off the hall .the nurse put the bracelet on me about a week ago . Resident #88 stated, I had gone downstairs to go outside to the courtyard. Resident #88 stated, .the staff came running, some gray headed woman and a tech seen me going that way and said you can't go outside .the next morning they put this bracelet on my leg . Resident 88 stated, .I like to go out to get some fresh air, I didn't get to go outside . Resident #88 stated, .I like to read or color outside .I pitched a fit and the nurse said you will probably get kicked out if you don't wear it .I haven't been outside since then . During an interview on 1/4/2024 at 8:45 AM, Resident #88 was asked if she had been able to go outside or to any group activities; Resident #88 responded, .No, I would like to see the blue sky. They are keeping me inside the building. I still have this bracelet, can't take it off and I feel like I am on house arrest. I use to go out to the courtyard on the 1st floor. I just want this thing off. I have told a couple of nurses .it is just to track me .they are trying to control me .I don't want to leave I just want to got outside . An observation and interview on 1/4/2024 at 4:20 PM revealed Resident #88 was observed with wanderguard bracelet in place on right ankle. Resident #88 stated, .I still have the ankle bracelet. I guess I will have to talk to [Named Administrator] about this bracelet if I ever get to go outside. I will probably have to wear it all the time until I finally get out of here . During an interview on 1/4/2024 at 4:30 PM, Licensed Practical Nurse (LPN) #18 was asked why Resident #88 had a wanderguard placed on her ankle. LPN #18 stated, .I understood she had walked downstairs, and the facility was afraid of her eloping .she walked out the door, I am not sure which door .she had gotten on the elevator went to Bingo on the 3rd floor and left Bingo got back on elevator and went down to 1st floor .[Named Resident #88] has complained about having to wear the bracelet, I don't feel like she wanted to wear it . LPN #18 was asked if Resident #88 had told her how the bracelet made her feel. LPN #18 stated, .I think the word she used was a prisoner . During a telephone interview on 1/27/2024 at 7:09 AM, LPN #41 was asked why she placed a wanderguard bracelet on Resident #88 on 12/30/2023. LPN #41 stated, .[Named Registered Nurse RN #3] asked me to place the bracelet .[Named Resident #88] had gone outside to the courtyard .[Named Resident #88] was back in her room and accounted for when I placed the bracelet .the courtyard does have a fence around it She [Named Resident #88] had the code to the door to go out [Named RN #3] will be here in 10 minutes you can call back and she can tell you more about what happened . LPN #41 was asked if [Named Resident #88] could have exited the courtyard. LPN #41 stated, No, she walks with a walker and the courtyard has a fence. During a telephone interview on 1/27/2024 at 7:35 AM, RN #3 was asked to explain why a wanderguard bracelet was placed on Resident #88. RN #3 stated, .She was .going out back in the courtyard She wasn't exiting the building . RN #3 was asked when does the facility place a wanderguard on a resident. RN #3 stated, When a patient is trying to exit the building. RN #3 was asked if [Named Resident #88] was trying to exit the building? RN #3 stated, She would normally ask to go outside .I explained to her that she can't go out without us knowing . During an interview on 1/30/2024 at 10:20 AM, Resident #88 stated, .I have had the code to go outside to the courtyard because I like to go out and look at the water that runs in front of the gate .It was the next day when they put the bracelet on me. I was just going outside; I wasn't leaving the building . Resident #88 was asked if she felt being made to wear the bracelet was against her rights. Resident #88 stated, Yes. During an interview on 1/31/2024 at 12:30 PM, the Regional Nurse Consultant #1 (recently designated Director of Nursing) was asked when should a wanderguard bracelet be placed on a resident. The Regional Nurse Consultant #1 stated, .if a resident was wandering without purpose which could be harmful to themselves .talk to the resident to see if the wandering was purposeful .diagnoses of Dementia .they would be at risk of leaving the facility . The Regional Nurse Consultant #1 was asked to explain the resident access to the gated courtyard for the facility. The Regional Nurse Consultant #1 stated, .it has a gate around it the residents have been allowed to go out to the courtyard . The Regional Nurse Consultant #1 was asked why Resident #88 received a wanderguard on 12/30/2023. The Regional Nurse Consultant #1 stated, .I haven't talked to [Named Resident #88] . During an interview on 1/31/2024 at 12:45 PM with Regional Nurse Consultant #1 present; Resident #88 was asked how the wanderguard bracelet made her feel. Resident #88 stated, .like I am in jail .I don't want to wear the bracelet .I told 2 nurses I didn't want to wear it .I was told if you're here you got to wear it. I just wanted to go outside and get some fresh air. I had the code to the door . During an interview in the courtyard on 1/31/2024 at 1:00 PM, the Maintenance staff #1 stated, .all the alert residents are given the code to the door to go out to the courtyard .there is a doorbell to ring when the resident wants to come back in from the courtyard .I haven't changed the code on the door in months because the residents should be able to go out when they want .

Based on facility policy review, facility video footage, hospital record review, www.accuweather.com review, medical record review, observation, and interview, the facility failed to provide an environment that remained free of accident hazards and failed to adequately supervise Resident #106. Resident #106 exited the building in his wheelchair when a staff member unlocked the front door for a visitor to exit. Resident #106 followed the visitor out the door unnoticed on 12/8/2023 at 12:31 PM. Resident #106 exited the building for a second time when a staff member again unlocked the front door for a visitor and Resident #106 followed the visitor out the door unnoticed on 12/8/2023 at approximately 1:35 PM. The facility was unaware of Resident #106 missing until approximately 9:00 PM on 12/8/2023 (7 1/2 hours after Resident #106 exited the front door). The facility was unable to find Resident #106. The facility failed to investigate and determine the root-cause and no new interventions were put into place immediately following the first incident. The facility failed to prevent Resident #106 from moving unsupervised from a safe environment to an unsafe environment on 12/8/2023 on two separate occasions. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Director of Nursing (DON) in the Administrator's office and the Administrator via telephone were notified of the Immediate Jeopardy on 12/20/2023 at 6:27 PM. The DON was given the IJ Template. The DON and the Administrator were given the opportunity to ask questions. The facility was cited Immediate Jeopardy at F-689 at the scope and severity of J, which is Substandard Quality of Care. The F689 Immediate Jeopardy began on 12/8/2023 through 12/28/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 12/28/2024 at 4:09 PM. The corrective actions were validated onsite by the surveyors on 12/29/2023. The facility's noncompliance at F689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility must submit a Plan of Correction. The findings include: Review of the facility policy titled Accidents Incidents Investigating, dated 5/19/2023 revealed, .All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the administrator .1.The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation for the accident or incident .k. Any corrective action taken .7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities . Review of the facility policy titled, Wandering and Elopements, dated 5/19/2023 revealed, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identifies as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner .b. get help from other staff members .c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises .3. If a resident is missing, initiate the elopement/missing resident emergency procedure: b. If the resident was not authorized to leave, initiate a search of the building (s) and premises . Review of the (facility) video footage dated 12/8/2023 revealed Resident #106 exited out the front door behind a visitor on 12/8/2023 at 12:31 PM, wearing his blue jean jacket and a beanie hat on with his Bible in his hand. He was seated in a wheelchair with his cane hanging to the right side of his wheelchair. Resident #106 rolled out to the entrance area, locked his wheelchair and transferred himself to the outside bench to the right of the exit door. The Former Interim Director of Nursing (IDON) #2 was standing in the lobby area when Resident #106 left behind a visitor. The Former IDON #2 looked out the exit door, started to walk away but turned around and exited the front door at 12:32 PM to talk to Resident #106. The Former IDON #2 then came back in the facility at 12:33 PM, Resident #106, continued to sit outside and transferred himself back to his wheelchair. While the Former IDON #2 was outside with Resident #106, the Business Office Manager talked to the Administrator and pointed to the exit door. The Administrator then exited the front door at 12:33:31 PM, talked to Resident #106, and the resident allowed the Administrator to roll him back into the facility and the resident rolled his wheelchair toward the 100 hall. Resident #106 came back to the front lobby at 1:29 PM. The Front Desk Clerk pushed the remote to open the front door for a visitor at 1:34:58 PM and the visitor exited the front door at 1:34:59 PM. The Front Desk Clerk turned his back to the exit door and left the desk at 1:35:01 PM. The Front Desk Clerk did not stay to monitor or visualize the closure of the front exit door and Resident #106 left the facility again behind a visitor without staff knowledge on 12/8/2023 at 1:35:13 PM. The Front Desk Clerk came back to the front desk at 1:35:30 PM along with Maintenance staff #1. Continued review of the video footage revealed during Resident #106's travel down the sloped sidewalk toward the street, 38 cars traveled the busy 4 lane road during a time span of 1 minute and 22 seconds. Within 1 second of Resident #106 rolling in his wheelchair, dropping off from the sidewalk to a lower level directly in front of the road, a car traveled by in front of Resident #106. Review of www.accuweather.com, the temperature in Nashville on 12/8/2023 was a low of 30 degrees Fahrenheit and a high of 51 degrees Fahrenheit. Review of Hospital #4's History and Physical for Resident #106 dated 9/30/2023 revealed, .[Named Resident #106] is a 77 YO [Year Old] .male with a PMH [past medical history] of HTN [Hypertension], arthritis (s/p status post hip replacement), homelessness .hx (history) of MI [Myocardial Infarction] who presented to the ED [Emergency Department] after 'passing out' in the bathroom of a Nashville .bus station early this morning. Patient originally from [NAME], TN [Tennessee] but had to relocate due to a house fire last Friday, during which he sustained no major injuries. Patient proceeded to stay with friends from various cities, including Memphis, TN and [NAME], TN, where he stayed overnight in [Named Hospital #5] for observation because of the smoke inhalation injury. Following this stay, patient rode the .bus to Nashville. Upon getting off the bus station, he went to go use the bathroom, during which he described feeling 'very hot'and immediately slumped onto the bathroom stall. He is unsure of how long he was out, but he remembers the officers pulling him out of the bathroom and performing sternal rubs . Continued review of Hospital #4's Progress Note for Resident #106 dated 10/2/2023 revealed .Chief Complaint .Where am I going to go, I lost everything .His chief concern .is no longer having a place to live after being displaced by an apt [apartment] fire .overall interview was tangential [relating to or along a tangent, diverging from a previous course or line; erratic thoughts} with pt [patient] referring to political and religious beliefs when asked about symptoms . Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] and exited the facility on 12/8/2023. Resident #106 was admitted with a diagnosis which included Syncope and Collapse, Essential Hypertension (HTN), Arthropathy, and Old Myocardial Infarction (MI). Review of Resident #106's Progress Notes revealed, .10/9/2023 .Physician Visit Note .Chief complaint weakness history of present illness the patient is a [AGE] year-old man with a history of hypertension arthritis hip replacement and homelessness who was admitted for further evaluation and treatment of weakness .He was thought to be dehydrated for the most part .was admitted to .hospital after being found unconscious in a bus station bathroom . Review of the 5-day scheduled Minimum Data Set (MDS) dated [DATE] revealed Resident #106's device used was a manual wheelchair, supervision required with walk 10 feet (ft) and walk 50 ft with two turns, walk 150 feet, walk 10 feet on uneven surfaces, and ability to go up and down a curb and/or up and down one step not attempted due to medical condition or safety concerns. Further review of the MDS revealed a fall in the last month. Review of Resident #106's Progress Notes revealed, .11/29/2023 .Nurse Practitioner Note .Patient seen for skilled follow up visit .He is asking to go outside, which is fine if he remains in courtyard area, requested that staff accompany him . Review of Resident #106's Progress Notes revealed, .12/9/2023 04:13 [4:13 AM] This resident was not in his room at change of shift [12/8/2023 7:00 PM] then Night shift nurse come to tell me he was still not in his room approximately 2200 (10:00 PM) so I announced CODE Grey [missing resident], so everyone was looking for him we could not find him [Named Registered Nurse RN #1] called [Named Administrator] and informed him. Resident's Supper tray was still in his room untouched. [Named Administrator] come out here to look for himself. Maintenance men [Both] were called in to look at the video tapes, so he was not in building when night shift arrived. I new [knew] he was not in his room when I went with the dayshift Nurse to look at his roommate before change of shift Approx [Approximately] 645 [6:45] PM, Dayshift Nurse and CNA [Certified Nursing Assistant] from first floor went outside looking for him we did not see him then later other staff went outside looking for him. Before the police arrived. Administrator .wanted to be called as he was out in his POV [Privately Owned Vehicle] looking for this resident he was informed once police arrived .[Named Administrator] and Maintenace man was on way back to this Facility at that time .Police was given all the information they asked for and was allowed to get a copy of this residents [resident's] photo so they would know who they were looking for . During an interview on 12/19/2023 at 2:40 PM, the SSD (Social Service Director) had no knowledge of a resident elopement in the last month. SSD stated, .I would have been made aware of any elopements . During an interview on 12/19/2023 at 2:55 PM, Licensed Practical Nurse [LPN] #5 stated, .that morning (12/8/2023) around 8:00 AM .I saw him [Resident #106] get on the elevator .I didn't really see him [Named Resident #106] after that . At 11:00 PM, [Named Registered Nurse RN #1], the night shift supervisor called and asked when the last time I seen [Named Resident #106].The agency nurse said [Named Resident #106] wasn't in his room, the nurse looked upstairs, and he couldn't be found .I don't think [Named Resident #106] was found that night. I worked the next day, and he wasn't there .the facility called the police and called the shelter to try to find him. The Maintenance staff and the tech went out looking for [Named Resident #106] .Maintenance staff #2 found his wheelchair outside . During an interview on 12/19/2023 at 3:18 PM, Maintenance #1 stated, .yes, we had a resident leave the facility. The Maintenance staff had to go out and look for [Named Resident #106]. I am 99% sure it was the Administrator that called me around 11:00 PM on 12/8/2023 and said, 'We had a resident missing.' I came in, reviewed the security footage and on 12/8/2023 at approximately 1:37 PM [Named Resident #106] was seen on the video footage exiting the building out the front door behind a visitor .[Named Resident #106] had been sitting up front close to the exit door and had already gone out once behind a visitor. The [Named Former IDON #2] went out to try and get him to come inside because we don't feel it is safe for residents to sit out front because traffic is heavy in that area. The Administrator then went out and talked to [Named Resident #106] and he agreed to come back in the facility around 12:15 PM on 12/8/2023, [Named Resident #106] goes back to 100 hall, he is on that hall about 1/2 hour .[Named Resident #106] then sits in his wheelchair waiting for his opportunity to exit the front door. He exited again behind a visitor in his wheelchair and goes down ramp until he goes out of security footage. No one noticed the resident going out. I reviewed the camera footage at the back, next to the apartments and [Named Resident #106] walks off .I did not ever find him. No employee was at the exit door when it happened, there was a 10 second gap of when [Named Front Desk Clerk] left the desk.[Named Resident #106] just went out behind someone . During an interview on 12/19/2023 at 3:45 PM, the Administrator stated, .I found out after [Named Resident #106] left that he told employees that day he was going to leave . The Administrator was asked on 12/8/2023 when he was notified [Named Resident 106] was missing? The Administrator stated, .I will try to recall the timing, around 9:30 or 10:00 PM. [Named Resident #106] was mobile around the center. He would do Bible study on different floors .I think [RN #1] notified me. [Named Maintenance staff #1] was able to look at security camera and seen when he [Named Resident #106] went out the front door [Named Resident #106] loved to be outside and about 1 hour prior, he did leave the building and sat on outside bench. I told him he needed to come back in. I discourage residents sitting on the front because several cars drive through this area .We notified the police department . During an interview on 12/19/2023 at 4:00 PM, Maintenance staff #1 revealed the video footage for [Named Resident #106] exiting the front door. The Maintenance staff #1 stated, .the facility has a remote that opens the exit door .It was hard for the staff behind the desk to see the exit door . During an interview on 12/19/2023 at 7:12 PM, RN #1 stated, .I was rounding around 8:30 - 9:00 PM and a nurse, I can't remember her name, she was on the 1st floor asked me if I had seen [Named Resident #106]. Usually, he would be in the bed at that time. I went to his room; his things were still in his room and his supper tray had not been touched. He kept a box on his table with his clothes in it .I immediately started looking for him and went outside .SSD said he didn't get discharged , techs said he was saying he was going home that day. We didn't get that in a nurse report that he was saying he was going home. He [Resident #106] was not found. The Administrator and the police came out to the facility. The Administrator . did tell me he [Resident #106] was homeless .The facility doesn't like for residents to sit out front because it is not safe. He [Named Resident #106] used the back courtyard to go outside sometimes .the nurse was doing her night medications and that is how she realized he was not here at the facility . During an interview on 12/20/2023 at 9:05 AM, Certified Nursing Assistant (CNA) #32 stated, .I delivered [Named Resident #106] food tray at lunch on 12/8/2023. He wandered around to other floors. He would eat his food, take a nap and go back upstairs .He said he was going home weekly. He said at the nurse's desk that day 'I am going home today' . During an interview on 12/20/2023 at 9:20 AM, CNA #19 stated (Named Resident #106) kept his stuff packed up all the time. During an interview on 12/20/2023 at 9:25 AM, CNA #33 (who was sitting and works at the front desk) stated, .the facility does an orientation related to working the front exit door .showed us how to work the phones .how to open the door .the camera is here for the front door so I can see who is coming to the door so I can let them in . CNA #33 was asked if she received any training related to watching the door when someone exits the building or educated on monitoring of the closing of the exit door. CNA #33 stated, No, we were told residents were not allowed to sit out front without someone being with them. During an interview on 12/20/2023 at 9:35 AM, Maintenance #2 stated, .I got a call that someone was missing. We went into action. I looked around the area for 1 1/2 hours. I think it was 11:00 PM when I got a call. I know it was Saturday morning before I got back home around 3:00 AM .He [Resident #106] would say all the time he was going to leave .I found his wheelchair the next day. It was over in front of our fence .I don't think we have someone sitting at the desk all the time . During an interview on 12/20/2023 at 10:45 AM, the Administrator stated, .[Named Former IDON #2] asked me to go speak to [Named Resident #106] because he was sitting outside at the front entrance and the staff all know, I am concerned about residents being in that area because of delivery trucks coming through this area .I would rather the residents go to the courtyard .Saturday [12/9/2023] morning .facts started to come out that he was saying he was going to leave . The Administrator was asked why the AMA (discharge Against Medical Advice) form was dated with his signature on 12/9/2023 (the day after Resident #106 left the facility)? The Administrator stated, .I completed that to state the reason he left. I did not talk to him about the risk of leaving AMA . The Administrator was asked if he reviewed the video footage? He stated, .I did not review the video footage . During an interview on 12/20/2023 at 11:33 AM, Respiratory Therapist #1 stated, .I saw [Named Resident #106] a couple of times .he told me he was leaving and asked 'Is that my discharge paperwork to go back home to my work?' I didn't know he was going to go out .I didn't tell anyone about what [Named Resident #106] said . During an interview on 12/20/2023 at 12:15 PM, Former IDON #2 stated, .I remember [Named Resident #106] .I did go outside when I saw him sitting on the bench out front and I told him he couldn't sit out front that he could sit outside in the courtyard. Then I told the Administrator and I had to leave for the day. It was normal for him to want to go out, but we don't want residents out front because it's not safe .he talked about going home all the time . During an interview on 12/20/2023 at 1:58 PM, the Director of Nursing [DON] and the Administrator revealed an investigation was not completed when [Named Resident #106] left the facility. The Administrator stated, .I didn't blame the receptionist [Named Front Desk Clerk] . The Administrator was asked when an incident or accident occurs what should the facility do? The Administrator stated, .1st thing to be done .a root cause analysis is what we should do . The Administrator was asked when [Named Resident #106] exited the facility behind a visitor without a staff member what did the facility do? The Administrator stated, .I didn't do anything about staff watching the exit door .I didn't consider an in-service related to the front door .I didn't see the exit door as being a problem. I don't think we did a Quality Assurance Performance Improvement [QAPI] meeting . During a telephone interview on 12/20/2023 at 3:52 PM, Dispatcher #1 for Police Department #1 stated, .I do see where they looked for [Named Resident #106]. No police report was completed . During a telephone interview on 12/20/2023 at 4:27 PM, Anonymous Employee #1 was asked if she was familiar with [Named Resident #106]. The Anonymous Employee #1 stated, .yes .I understood his home burned down about a month ago . The Anonymous Employee #1 stated, .at 10:38 PM on 12/8/2023 a group chat for the facility went out [to facility staff members] through an app the facility uses .[Named RN #1] was reaching out to see if he had been discharged .multiple [staff members] were in the text .[Named RN #1] had not seen him. His dinner tray in his room was untouched .He [Named Resident #106] was confused at times . Anonymous Employee #1 was asked to give examples of times [Named Resident #106] was confused. Anonymous Employee #1 stated, .for example .he said if he could make it to the airport, he had security there to pick him up. He would not use a telephone, said people were getting hooked on phones and people were being tracked that way .told me if I ever needed to reach him to dial W975 .he had a house fire because he was intertwined with the Mob, so they burned his house down .he talked about conspiracy theory .I know the facility is trying to say he went AMA [Against Medical Advice] but that isn't true . During an interview on 1/3/2024 at 12:10 PM, the Administrator stated, .no one saw [Named Resident #106] leave .he didn't take any of his things .he stated he was going to leave to 3 different staff members .he planned to leave he was watching the door .I would have liked for the staff to identify the resident was missing sooner . During an interview and observation on 1/10/2024 at 8:45 AM, the Administrator and Maintenance #1 was asked to perform a wheeled measurement of the footage (Named Resident #106) traveled until the video footage no longer captured him rolling from the facility and where (Named Resident #106)'s wheelchair was found. The observation revealed (Named Resident #106) traveled in his wheelchair down the sloped sidewalk 198 feet before dropping off a ledge (height of 6 3/4 inches) to the street sidewalk (18.5 feet from the road) and out of video surveillance range. Continued observation and interview revealed (Named Resident #106)'s wheelchair was found 473 feet away from the facility. The wheelchair was found adjacent to a parking lot for an apartment complex and a family clinic. Maintenance #1 stated, .the clinic had noticed the wheelchair sitting outside our gate near the picnic area . During an interview on 1/10/2024 at 4:00 PM, the Administrator stated, .We were able to get in contact with [Named Resident #106] he is in a town in Memphis at a friend's home. We have [Named Family/Friend #19-]'s phone number . During a telephone interview on 1/10/2024 at 8:10 PM, (Named Family/Friend #19) stated, .[Named Resident #106] called me needing somewhere to stay .he showed up in a taxi .he said he had been to California then Nashville and I live in [NAME] TN and that is where he is now . I asked (Named Family/Friend #19) if I [this surveyor] could speak to (Named Resident #106). (Named Family/Friend #19) stated, He isn't with me right now he is staying at the house next door .I can have him call you . On 1/11/2024 at 12:55 PM, This surveyor received a call from (named Family/Friend #19) and stated, (Named Resident #106) was with her and wanted to speak to me. (Named Resident #106) was asked why he left the Skilled Nursing Facility (SNF) #1. (Named Resident #106) stated, .God opened to door for me, so I rolled out .I almost got hit in the highway .that place thought I was a troublemaker because they thought I was investigating something .you know they got drugs running through that building giving it to those patients .they didn't want me to find out anything . There was no information given as to when Resident #106 arrived in Memphis, TN. He left the faciity on [DATE] and on 1/10/24 was the first communication with Resident #106 since he left the facility. (33 days)

Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the facility failed to identify, assess, implement and monitor quality deficiencies which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) for 1 of 2 residents (Resident #3) reviewed for blood glucose monitoring. The facility also failed to identify, assess, implement and monitor processess for wound evaluations and documentation for 3 of 7 residents (Resident #17,#18, and #20) requiring wound care for pressure ulcers, which did not rise to the level of IJ. The Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 1/27/2021 at 7:30 PM in the Conference room. F-867 and F-880 were cited at a scope and severity of J. A partial extended survey was conducted from 1/27/2021 through 1/28/2021. The Immediate Jeopardy was effective from 1/27/2021 through 1/28/2021. An immediate action removal plan, which removed the immediacy of the jeopardy, was received on 1/27/2021 at 9:00 PM and corrective actions were validated onsite by the surveyors on 1/28/2021 through observation and staff interviews. The findings include: Review of the QAPI Committee policy, dated July 2016, showed, .this facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) committee that oversees the implementation of the QAPI Program .the primary goals of the QAPI Committee are to establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services' promote the consistent use of facility systems and processes during provision of care and service; help identify actual and potential negative outcomes relative to resident care and resolve them appropriately . Review of the Glucometer Manufacturer Guideline, Caring for Your System, undated, showed, .The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure .the disinfection procedure is needed to prevent transmission of blood-borne pathogens .the meter should be cleaned and disinfected after use on each patient .This blood glucose monitoring system may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . Review of the policy titled, Obtaining a Fingerstick Glucose Level,dated October 2011, showed, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Review of undated facility policy, NURSING POLICY AND PROCEDURE SKIN WOUND CARE PROTOCOLS AND POLICY, showed, .To the extent possible, to ensure nursing policy and procedures required by the facility are of clinical practice are performed safety (safety), consistency (consistantly), and where ever possible based on current research, evidence based nursing .To provide skin and wound care protocols for use in determining appropriate interventions . Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#3, dated January 27, 2021, showed, .accucheck (fingerstick blood glucose level testing) BID (twice daily) . Observation and interview conducted on 1/27/2021 at 5:35 PM with Registered Nurse (RN) #2 showed RN #2 obtaining a glucometer from a medication cart on the 200 East hallway. Continued observation of RN #2 showed she did not disinfect the glucometer prior to entering Resident #3's room. Continued observation showed RN #2 entering Resident #3's room and explaining the fingerstick blood glucose (FSBG) procedure to the resident. Continued observation showed RN #2 proceeding to prepare the resident's finger for the FSBG testing when this surveyor intervened. Continued interview with RN #2 outside of Resident #3's room, when asked the procedure for obtaining a resident's FSBG, RN #2 confirmed she had not disinfected the glucometer prior to entering Resident #3's room to obtain the resident's FSBG. Continued interview with RN #2 she stated, I clean the glucometer with bleach wipes when I come on my shift and before I leave my shift. I do not clean it between resident. I never have. This is my 10th shift here and I have been coming here since July (2020). No one ever told me I had to. Continued interview with RN #2, she stated she was not oriented by facility staff on glucometer cleaning. Observation and interview on 1/27/2021 at 5:47 PM with the Staff Development Coordinator/Infection Preventionist (SDC/IP) in the presence of RN #2, confirmed glucometers were to be cleaned with bleach wipes and allowed to air dry before and after each resident use. The SDC/IP stated staff are oriented to this procedure on hire prior to taking care of residents. She then turned to RN #2 and asked her if she had been oriented, and RN #2 stated,no. Review of the medical record showed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's Physicians Order Recaputitulation Report showed there were no wound care orders until 1/22/2021; 5 days after the resident was admitted to the facility with a Stage 3 (involves full thickness of the skin and may extend into the subcutaneous (fatty) tissue layer) pressure ulcer. Review of Resident #17's care plan showed, .At risk for pressure injury development related to Decrease in Mobility, Recent Change in Condition .frequent repositioning .Elevate heels off of bed surface .Notify nurse immediately of any new areas of skin breakdown .Remind/assist resident to frequently change position when in bed and/or chair . Review of Resident #17's medical record showed no turn schedule was in place for Resident #17 until 1/21/2021; 4 days after the resident was admitted with a stage 3 pressure ulcer. Review of the medical record showed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Comprehensive Minimum Data Set (MDS), dated [DATE], showed, the resident required extensive assistance with a 2 person assist for the following ADLs (Activities for Daily Living): Bed mobility and Transfer. Further review showed Resident #18 was at risk for pressure ulcers. Review of Resident #18's weekly wound care evaluations showed 3 of 8 evaluations were not completed in 7 days: The 12/15/2020 wound assessment was not completed for 10 days. The 12/24/2020 wound assessment was not completed for 9 days, and the 1/3/2021 wound assessment was not completed for 10 days. Review of the medical record showed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20's Comprehensive admission MDS dated [DATE], showed Resident #20 had 5 unstageable pressure ulcers on admission. Review of Resident #20's Treatment Administration Record (TAR) showed wound care for bilateral buttocks: .Clean with [MEDICATION NAME] 4% (medicated wound cleanse) pack with calcium alginate (medicated absorbant gauze) wrapping in dry gauze, cover DCD (dry clean dressing) every day shift . Order for treatment dated 1/22/2021 was not documented on 1/25/2021 and 1/26/2021. Review of Resident #20's TARS dated 1/1/2021-1/31/2021, showed wound care for bilateral heels: .Clean with NSS (normal saline solution) and apply providone/iodine, wrap with [MEDICATION NAME] every day shift .order dated 1/22/2021 . Continued review showed treatments were not documented on the following dates: 1/25/2021 and 1/26/2021. Review of Resident #20's TAR dated 1/1/2021-1/31/2021 showed .Midline abdominal Incision: Clean with NSS, apply foam, and connect to wound vac @ (at) 125 mmHg. Every Mon (Monday), Wed (Wednesday), Fri (Friday) .order dated 12/30/2020 . Continued review showed treatments were not documented on the following dates: 1/1/2021, 1/8/2021, 1/15/2021 and 1/20/2021, and 1/25/2021; a total of 5 of 11 scheduled treatments had not been documented. During an interview on 1/28/2021 at 4:00 PM with the DON, she confirmed there was no system in place for monitoring wound treatment. During further interview she confirmed she had not been monitoring nursing staff to ensure proper infection control practices were followed related to cleaning of the glucometers. During continued interview she confirmed the facility process for identification of concerns, assessment, implementation and monitoring of wound care was incomplete. The immediate action removal plan was verified by the surveyors by: 1. On 1/27/2021 the glucometer was immediately removed from the medication cart on the 200 East hall, cleaned and disinfected by the Unit Manager according to the manufacturer's guidelines. All other glucometers in the facility were cleaned by the Unit Managers according to the manufacturer's guidelines. RN #2 was educated on 1/27/2021 by the Staff Development Coordinator/Infection Control Preventionist as well as a Glucometer Competency was completed. Surveyor observed RN #2 perform FSBG on Resident #3 using proper disinfecting technique of the glucometer per manufacturer's guideline. The 2 residents who received blood glucose monitoring by RN #2 on the 200 East Hall were assessed by the SDC/IP with no concerns identified. An Adhoc Quality Assurance Performance Improvement (QAPI) meeting was conducted by the Administrator on 1/27/2021 to ascertain root cause and discuss the facility plan. 2. The surveyors reviewed the blood glucose monitoring education and competencies for glucometers and obtaining a FSBG for testing for all nurses present on 1/27/2021 and 1/28/2021. The surveyor observed 2 glucometers on each medication cart in the facility. The surveyor reviewed the QAPI meeting plan. The surveyor observed RN #2 perform FSBG with proper disinfecting technique of the glucometer per manufacturer's guideline on 1/27/2021. 3. On 1/27/2021 and 1/28/2021 staff interviews were conducted to verify education and competency of disinfecting glucometers before and after each resident use. Surveyors verified nursing staff education and competency for staff on duty on 1/27/2021 and 1/28/2021 by interviews and reviewing the sign in competency sheet for Glucometer competency and obtaining FSBG dated 1/27/2021 and 1/28/2021. Surveyors reviewed QAPI plan for all residents identified with pressure wounds. All Residents with wounds will be assessed by a certified physician. Education by the facility began 1/28/2021 to include implementation and monitoring of the wound care process and all identified concerns will be assessed and reported to the facility QAPI Committee by the DON and Administrator Monthly.

Amended 2/19/2021 Based on the facility's Quality Assurance Performance Improvement (QAPI) Plan review, policy review, medical record review, and interview, the QAPI Committee failed to identify quality deficiencies which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) for 3 of 7 residents (Resident #17,#18, and #20) requiring wound care and 1 of 2 residents (Resident #3) reviewed for blood glucose monitoring. The Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 1/27/2021 at 7:30 PM in the Conference room. F-867 and F-880 were cited at a scope and severity of J. A partial extended survey was conducted from 1/27/2021 through 1/28/2021. The Immediate Jeopardy was effective from 1/27/2021 through 1/28/2021. An immediate action removal plan, which removed the immediacy of the jeopardy, was received on 1/27/2021 at 9:00 PM and corrective actions were validated onsite by the surveyors on 1/28/2021 through observation and staff interviews. The findings include: Review of the QAPI Committee, dated July 2016, showed, .this facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) committee that oversees the implementation of the QAPI Program .the primary goals of the QAPI Committee are to establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services; promote the consistent use of facility systems and processes during provision of care and service; help identify actual and potential negative outcomes relative to resident care and resolve them appropriately . Review of the Glucometer manufacturer guideline,Caring for Your System, undated, showed, .The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure .the disinfection procedure is needed to prevent transmission of blood-borne pathogens .the meter should be cleaned and disinfected after use on each patient .This blood glucose monitoring system may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . Review of the policy titled, Obtaining a Fingerstick Glucose Level,dated October 2011, showed, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Review of undated facility policy,NURSING POLICY AND PROCEDURE SKIN WOUND CARE PROTOCOLS AND POLICY, showed, .To the extent possible, to ensure nursing policy and procedures required by the facility are of clinical practice are performed safety[safety], consistency[consistently], and where ever possible based on current research, evidence based nursing To provide skin and wound care protocols for use in determining appropriate interventions . Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .accuchecks BID [twice daily] . Observation and interview conducted on 1/27/2021 at 5:35 PM with Registered Nurse (RN) #2 showed RN #2 obtaining a glucometer from a medication cart on the 200 East hallway. Continued observation of RN #2 showed she did not disinfect the glucometer prior to entering Resident #3's room. Continued observation showed RN #2 entering Resident #3's room and explaining the fingerstick blood glucose (FSBG) procedure to the resident. Continued observation showed RN #2 proceeding to prepare the resident's finger for the FSBG testing when this surveyor intervened. Continued interview with RN #2 outside of Resident #3's room, when asked the procedure for obtaining a resident's FSBG, RN #2 confirmed she had not disinfected the glucometer prior to entering Resident #3's room to obtain the resident's FSBG. Continued interview with RN #2 she stated, I clean the glucometer with bleach wipes when I come on my shift and before I leave my shift; I do not clean it between residents; I never have; this is my 10th shift here and I have been coming here since July [2020]. No one ever told me I had to. Continued interview with RN #2, she stated she was not oriented by facility staff on glucometer cleaning. Observation and interview on 1/27/2021 at 5:47 PM with the Staff Development Coordinator/Infection Preventionist (SDC/IP) in the presence of RN #2, confirmed glucometers were to be cleaned with bleach wipes and allowed to air dry before and after each resident use. The SDC/IP stated staff are oriented to this procedure on hire prior to taking care of residents. She then turned to RN #2 and asked her if she had been oriented, and RN #2 stated,no. Interview on 1/28/2021 at 4:00 PM, with the Director of Nursing in the conference room, when asked the process of monitoring for infection control related to the glucometer disinfection, she confirmed there was no system in place and she had not been monitoring nursing staff to ensure proper infection control practices were followed. Review of the medical record showed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Order Recap Report showed there were no wound care orders until 1/22/2021; 5 days after the resident was admitted to the facility with a Stage 3 (involves full thickness of the skin and may extend into the subcutaneous [fatty] tissue layer) pressure ulcer. Review of Resident #17's care plan showed, .At risk for pressure injury development related to Decrease in Mobility, Recent Change in Condition .frequent repositioning .Elevate heels off of bed surface .Notify nurse immediately of any new areas of skin breakdown .Remind/assist resident to frequently change position when in bed and/or chair . Review of Resident #17's medical record showed no turn schedule was in place for Resident #17 until 1/21/2021; 4 days after the resident was admitted with a stage 3 pressure ulcer. Review of the medical record showed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Comprehensive Minimum Data Set (MDS), dated [DATE], showed, the resident required extensive assistance with a 2 person assist for the following ADL's (activities for daily living): Bed mobility and Transfer. Further review showed Resident #18 was at risk for pressure ulcers. Review of Resident # 18's weekly wound care evaluations showed 3 of 8 evaluations were not completed in 7 days: 12/15/2020-completed in 10 days, 12/24/2020-completed in 9 days, 1/3/2021-completed in 10 days. Review of the medical record showed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Comprehensive MDS dated [DATE], showed Resident #20 had 5 unstageable pressure ulcers on admission. Review of Resident #20's TARs (Treatment Administration Record) showed wound care for bilateral buttocks: .Clean with chlorhexidine [MEDICATION(S)] 4% pack with calcium alginate wrapping in dry gauze, cover DCD (dry clean dressing) every day shift . Order for treatment dated 1/22/2021 was not charted on 1/25/2021 and 1/26/2021. Review of Resident #20's TARs dated 1/1/2021-1/31/2021, showed wound care for bilateral heels: .Clean with NSS (normal saline solution) and apply providone/iodine, wrap with [MEDICATION(S)] every day shift .order dated 1/22/2021 . Continued review showed treatments were not charted on the following dates: 1/25/2021 and 1/26/2021. Review of Resident #20's TARs dated 1/1/2021-1/31/2021 showed .Midline abdominal Incision: Clean with NSS, apply foam, and connect to wound vac @ [at] 125 mmHg. Every Mon (Monday), Wed (Wednesday), Fri (Friday) .order dated 12/30/2020 . Continued review showed treatments were not charted on the following dates: 1/1/2021, 1/8/2021, 1/15/2021 and 1/20/2021, and 1/25/2021; a total of 5 of 11 scheduled treatments were not documented. During an interview on 1/28/2021 at 3:42 PM with the DON, she confirmed if the resident did not have wound care orders on admission, the facility would have relied on the nurse practitioner or the medical director to provide wound care orders. During further interview she confirmed wound care orders should be obtained within 24 hours of admission. During further interview she confirmed, skin assessments were to be completed weekly unless something new is found, and wound evaluations would also be completed weekly; I don't have a full-time wound nurse. During continued interview she stated the system failure would be not having a wound nurse, not getting documentation timely, and not having the wounds measured consistently. During continued interview she stated she expects any resident with wounds to have skin assessments and wound evaluations every 7 days until the wound is healed. The immediate action removal plan was verified by the surveyors by: 1. On 1/27/2021 the glucometer was immediately removed from the medication cart on the 200 East hall, cleaned and disinfected by the Unit Manager according to the manufacturer's guidelines. All other glucometers in the facility were cleaned by the Unit Managers according to the manufacturer's guidelines. The nurse on the 200 East Hall medication cart was educated on 1/27/2021 by the Staff Development Coordinator/Infection Control Preventionist as well as a Glucometer Competency was completed. Surveyor observed RN #2 perform FSBG on Resident #3 using proper disinfecting technique of the glucometer per manufacturer's guideline. The 2 residents who received blood glucose monitoring by this nurse on the 200 East Hall were assessed by the SDC/IP with no concerns identified. An Adhoc Quality Assurance Performance Improvement (QAPI) meeting was conducted by the Administrator on 1/27/2021 to ascertain root cause and discuss the facility plan. 2. The surveyors reviewed (all nurses present on 1/27/2021 and 1/28/2021) the education and competencies for glucometers and obtaining a FSBG for testing. The surveyor observed 2 glucometers on each medication cart in the facility. The surveyor reviewed the QAPI meeting plan. The surveyor observed RN #2 perform FSBG with proper disinfecting technique of the glucometer per manufacturer's guideline on 1/27/2021. 3. On 1/27/2021 and 1/28/2021 staff interviews were conducted to verify education and competency of disinfecting glucometers before and after each resident use. Surveyors verified nursing staff education and competency for staff on duty on 1/27/2021 and 1/28/2021 by interviews and reviewing the sign in competency sheet for Glucometer competency and obtaining FSBG dated 1/27/2021 and 1/28/2021. Surveyors reviewed QAPI plan for all residents identified with pressure wounds are to be assessed by a certified physician.

Based on the glucometer manufacturer guideline, policy review, medical record review, observation, and interview, the facility failed to follow standard precautions during the performance of routine fingerstick blood glucose (FSBG) testing resulting in potential exposure of residents who required blood glucose testing to prevent the spread of bloodborne pathogens in the facility for 1 of 2 diabetic residents (Resident #3) requiring FSBG testing, placing Resident #3 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility failed to maintain infection control practices during supper meal tray pass on 1/27/2021 related to 1 of 2 Certified Nursing Assistants (CNA) not performing hand hygiene between resident trays which did not rise to the level of IJ. The Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 1/27/2021 at 7:30 PM in the Conference room. F-880 was cited at a scope and severity of J. A partial extended survey was conducted from 1/27/2021 through 1/28/2021. The Immediate Jeopardy was effective from 1/27/2021 through 1/28/2021. An immediate action removal plan, which removed the immediacy of the jeopardy, was received on 1/27/2021 at 9:00 PM and corrective actions were validated onsite by the surveyors on 1/28/2021 through observation and staff interviews. The findings include: Review of the Glucometer manufacturer guideline,undated, Caring for Your System, showed, .The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure .the disinfection procedure is needed to prevent transmission of blood-borne pathogens .the meter should be cleaned and disinfected after use on each patient .This blood glucose monitoring system may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . Review of the policy titled, Obtaining a Fingerstick Glucose Level, dated October 2011, showed, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Review of the policy, undated, titled COVID-19, showed, Hand Hygiene .Health care personnel should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process .Health care personnel should perform hand hygiene by using ABHR (Alcohol Base Hand Rub) with 60-96% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR . Review of Registered Nurse (RN) #2's employee record showed RN #2 began employment with the facility July 2020 with her first shift on 8/29/2020. Continued review showed RN #2 had worked 11 shifts from 8/29/2020 through 1/27/2021. Continued review showed RN #2 received training on use of glucometers and performing fingersticks on 7/8/2020 from (named) staffing agency. Continued review showed no orientation or competency training from the facility for glucometers and/or obtaining a FSBG for testing. Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#2 dated 1/15/2021, showed, .accuchecks (fingerstick blood glucose test) BID (twice daily) . Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#3 dated 1/ 1, showed, .accucheck BID . Observation and interview conducted on 1/27/2021 at 5:35 PM with RN #2 showed RN #2 obtaining a glucometer from a medication cart. Continued observation showed RN #2 preparing the glucometer for resident use. Continued observation revealed RN #2 did not disinfect the glucometer prior to entering Resident #3's room. Continued observation showed RN #2 entering Resident #3's room and explaining the FSBG procedure to the resident. Continued observation showed RN #2 proceeding to prepare the resident's finger for the FSBG testing when this surveyor intervened. Continued interview with RN #2 outside of Resident #3's room, when asked the procedure for obtaining a resident's FSBG, RN #2 confirmed she had not disinfected the glucometer prior to entering Resident #3's room to obtain the resident's FSBG. During continued interview RN #2 stated, I clean the glucometer with bleach wipes when I come on my shift and before I leave my shift, I do not clean it between residents. I never have. this is my 10th shift here and I have been coming here since July (2020). Continued interview when asked if she had performed any other FSBG testing prior to Resident #3, she stated, yes, on (named Resident #2) but I cleaned it before him because he was my first stick. Observation and interview on 1/27/2021 at 5:47 PM with the Staff Development Coordinator/Infection Preventionist (SDC/IP) in the presence of RN #2, confirmed glucometers were to be cleaned with bleach wipes and allowed to air dry before and after each resident use. The SDC/IP stated staff are oriented to this procedure on hire prior to taking care of residents. She then turned to RN #2 and asked her if she had been oriented and RN #2 stated, no. Observation on 1/27/2021 at 5:00 PM showed Certified Nurse Assistant (CNA) #5 take a meal tray off the tray cart and serve it to a resident. Continued observation showed she was not wearing gloves nor was she observed using alcohol based hand rub (ABHR). Continued observation showed she served the tray and then went into room [ROOM NUMBER] and pulled a resident up in bed. She exited the room without performing hand hygiene and went down the hall where she encountered a resident in the hallway. She assisted the resident back to her room, did not wash her hands and continued down the hall to room [ROOM NUMBER]. She then assisted a resident in room [ROOM NUMBER] and did not perform hand hygiene afterwards. During an interview on 1/27/2021 at 4:20 PM with Licensed Practical Nurse (LPN) #2 she stated staff ensure they are keeping residents safe and protected from infection by wearing gloves, changing gowns, and washing hands between each patient contact. During continued interview LPN #2 stated, Cross contamination is prevented by wearing our PPE (personal protective equipment), keeping doors shut, and washing hands. Interview on 1/27/2021 at 5:15 PM with CNA #5 confirmed she had not performed hand hygiene while serving trays and assisting residents for the past 15 minutes. During continued interview she confirmed she should have performed hand hygiene between each resident contact and between touching meal trays. During an interview on 1/28/2021 at 4:00 PM with the Director of Nursing confirmed her expectations were for nurses to clean glucometers before and after each resident use and staff were to be oriented to the processes before taking care of residents. Continued interview she stated she had not been monitoring nursing staff to ensure proper infection control practices were followed related to cleaning of the glucometers. The immediate action removal plan was verified by the surveyors on 1/28/2021 by: 1. On 1/27/2021 the glucometer was immediately removed from the medication cart on the 200 East hall; cleaned and disinfected by the Unit Manager according to the manufacturer's guidelines. All other glucometers in the facility were cleaned by the Unit Managers according to the manufacturer's guidelines. RN #2 was educated on 1/27/2021 by the Staff Development Coordinator/Infection Control Preventionist as well as a Glucometer Competency was completed. Surveyor observed RN #2 perform FSBG on Resident #3 using proper disinfecting technique of the glucometer per manufacturer's guideline. The 2 residents who received blood glucose monitoring by RN #2 on 200 East Hall were assessed by the SDC/IP with no concerns identified. An Adhoc Quality Assurance Performance Improvement (QAPI) meeting was conducted by the Administrator on 1/27/2021 to ascertain root cause and discuss the facility plan. 2. The surveyors reviewed the blood glucose monitoring education and competencies for glucometers and obtaining a FSBG for testing for all nurses present on 1/27/2021 and 1/28/2021. The surveyor observed 2 glucometers on each medication cart in the facility. The surveyor reviewed the QAPI meeting plan. The surveyor observed RN #2 perform FSBG with proper disinfecting technique of the glucometer per manufacturer's guideline on 1/27/2021. 3. On 1/27/2021 and 1/28/2021 staff interviews were conducted to verify education and competency of disinfecting glucometers before and after resident use. Surveyors verified nursing staff education and competency for staff on duty on 1/27/2021 and 1/28/2021. Surveyors interviewed licensed staff and reviewed the sign-in competency sheet for Glucometer competency and obtaining FSBG dated 1/27/2021 and 1/28/2021. The noncompliance of F-880 continues at a scope and severity of D level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, observation, and interview the facility failed to develop and implement a person-centered care plan for 3 of 41 residents (Resident #60, #4 and #57) reviewed for Comprehensive Care Plans placing the residents in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). Resident #60 experienced a fall which resulted in a C7 fracture ([MEDICAL CONDITION] neck vertebra) and a second fall which resulted in a Proximal Left [MEDICAL CONDITION] (Fracture at the base of the Femoral Neck). Resident #4 experienced a fall which resulted in a Traumatic Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain related to trauma). Resident #4 then developed a new onset of [MEDICAL CONDITION] activity after the fall. Resident #57 was left unattended in the bathroom, fell while self-toileting and sustained a Left Humerus (upper arm) Fracture. The Administrator was notified of the Immediate Jeopardy (IJ) on 2/4/2020 at 10:05 PM in the Director of Nursing's (DON) office. F-656 was cited at a scope and severity of [NAME] An extended survey was conducted from 2/4/2020 through 2/7/2020. The Immediate Jeopardy was effective from 7/3/2019 to 2/6/2020. An Immediate Action Removal plan which removed the immediacy of the Jeopardy was received on 2/7/2020 at 12:30 PM and corrective actions were validated on site by the surveyors on 2/7/2020. The findings include: Review of the undated facility policy title, Comprehensive Care Planning, revealed .The facility will develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psyschosocial needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence .The care plan will describe the services that are to be furnished to attain or maintain in the resident's highest practicable physical, mental, and psychosocial well-being, and any services that would otherwise be required but are not due to resident's right, including the right to refuse treatment .Care Plan Team members include but are not limited to: Certified Nursing Assistant (CNA) who is responsible for the resident's care . Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed the resident was readmitted on [DATE] with a new [DIAGNOSES REDACTED]. Continued review showed a new [DIAGNOSES REDACTED]. Further review showed a new [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #60 had severe cognitive impairment, his vision is highly impaired, he required supervision with ambulation and most other activities of daily living (ADLs) and required limited assistance with transferring from a chair to a standing position with one person physical assistance. Review of Resident # 60's comprehensive care plan revealed no interventions for supervision with ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #60 was assessed at a high risk for falls. Review of the interdisciplinary post fall review dated 7/3/2019, revealed .Resident #60 fell on [DATE], he was found in a supine position on the floor in another resident's room .the fall was unwitnessed . Review of the POS [REDACTED].Patient is pleasantly confused male, resident of (Named Facility). He was found by staff down on the floor. It was unwitnessed. Patient was unable to provide additional details .In the work-up, he was found to have compression fracture of C7 .C collar (cervical collar (neck brace)) was recommended . Review of the fall risk assessment dated [DATE] revealed Resident #60 continued to be at high risk for falls. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #60 had severe cognitive impairment, his vision was highly impaired, and he required 1 person physical assistance with walking, transfers and locomotion on and off the unit. Review of Resident # 60's comprehensive care plan revealed no interventions were added to include 1 person physical assist with walking and locomotion on and off the unit. Review of the fall risk assessment dated [DATE], revealed Resident #60 continued to be at high risk for falls. Review of the interdisciplinary post fall review dated 12/24/2019, revealed Resident #60 had a second unwitnessed fall on 12/23/2019 .The resident was found in the doorway of another resident's room . Review of Resident #60's radiology report dated 12/24/2019, revealed .Proximal left [MEDICAL CONDITION] . Review of Resident #60's undated Comprehensive Care Plan confirmed there were no interventions for supervision with ambulation were developed or implemented before, or after, the fall on 7/3/2019 which resulted in a fractured neck. Review of Resident # 60's comprehensive care plan confirmed no interventions for 1 staff physical assistance with walking and locomotion on and off the unit were developed or implemented after the fall on 12/23/2019 which resulted in a [MEDICAL CONDITION]. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review showed the resident was readmitted on [DATE], with new [DIAGNOSES REDACTED]. Continued review showed a new [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], revealed Resident #4 was rarely or never understood and walking in the room and corridor required supervision. Review of the fall risk assessments dated 7/23/2019 and 11/18/19 revealed Resident #4 was at high risk for falls. Review of the POS [REDACTED]. Review of Resident # 4's comprehensive care plan revealed no intervention for supervision was added after the 7/23/2019 fall. Review of the fall risk assessment dated [DATE], and 10/7/2019, revealed Resident #4 continued to be at high risk for falls. Review of the POS [REDACTED].Resident #4 had a fall with injuries on 10/7/2019 which resulted in Traumatic Subarachnoid Bleed . Review of the fall risk assessments dated 10/10/2019 and 11/18/2019 revealed Resident #4 continued to be at high risk for falls. During an interview on 2/5/2020 at 3:18 PM, Nurse Practitioner #1 confirmed Resident #4's fall on 10/7/2019, was unwitnessed. Review of Resident #4's Comprehensive Care Plan confirmed no interventions for supervision or assistance with ambulation were added after the following falls: 7/23/2019, 10/7/2019 and 11/10/2019. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #57's comprehensive care plan dated 7/18/2019, revealed she required transfer by mechanical lift with the assistance of 2 staff and moderate assistance of 1 staff to assist with toileting and hygeine. Review of Resident #57's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Further review revealed Resident #57 required extensive assistance with 1 person moderate assist with transfers, toileting use, and personal hygiene. Review of Resident #57's Interdisciplinary Post Fall Review dated 12/24/2019, revealed .unwitnessed fall .resident was attempting to wipe herself after a bowel movement .resident found on the floor of the bathroom when Certified Nursing Assistant (CNA) #2 returned to the room . Review of Resident #57's fall report dated 12/24/2019 revealed .patient tried to stand up to wipe herself after having a bowel movement and fell .gait imbalance .unaware of physical limitations .history of falls .(named CNA 2) was educated per (by) the Unit Manager regarding the importance of staying near the bathroom or outside the door to promote safety while providing privacy . During a telephone Interview with CNA #2 on 2/4/2020 at 10:30 PM she confirmed she failed to implement the Resident's care plan when she left the resident alone in the bathroom and went to the linen cart. The Immediate Action Removal Plan was verified by the surveyors on 2/7/2020 by: 1. The surveyors verified through review of care plans and staff interviews the care plan interventions were implemented for Residents #4, #57 and #60. Resident #4's Care Plan was was updated to reflect staff will offer assistance with ambulation. Resident #57's Care Plan was updated to reflect she required moderate assistance with toileting. Resident #60's Care Plan was updated to include bilateral fall mats when in bed and bed in low position. 2. The surveyors verified all safety interventions were in place for 3 residents (#4, #57 and #60). The surveyors verified the facility's 100% audit of residents who were at risk for falls and reviewed the care plans for the residents at risk. 3.The surveyors reviewed and verified the Fall Prevention and ADL's/Functional Status education and training was completed for the Certified Nursing Assistants who were present (90% of the CNA staff) on 2/6/2020. The remaining 10% will receive education by 2/10/2020. The surveyors verified the facility held an AdHoc/QAPI meeting (an immediate meeting by Administrative staff to address the immediate situation) on 2/5/2020 to include discussion related to fall prevention and care plan implementation. The facility's noncompliance at F-656 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review and interview, the facility failed to provide supervision and assistance for 3 of 4 residents (Resident #60, #4, and #57) reviewed for falls with major injury which placed these residents in Immediate Jeopardy when Resident #60 experienced a fall which resulted in a C7 fracture ([MEDICAL CONDITION] neck vertebra) and a second fall which resulted in a Proximal (point of attachment) Left [MEDICAL CONDITION]. Resident #4 experienced a fall which resulted in a Traumatic Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain related to trauma). Resident #4 then developed new onset [MEDICAL CONDITION] activity after the fall. Resident #57 was left unattended in the bathroom, fell while self-toileting, and sustained a Left Humerus (upper arm) fracture. The facility's noncompliance placed Resident #60, #4 and #57 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy (IJ) on 2/4/2020 at 10:05 PM in the Director of Nursing's (DON) office. F-689 was cited at scope and severity of J, which is Substandard Quality of Care. An extended survey was conducted from 2/4/2020 through 2/7/2020. The Immediate Jeopardy was effective from 7/3/2019 to 2/6/2020. An Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 12:30 PM, and corrective actions were validated on site by the surveyors on 2/7/2020. The findings include: Review of the facility policy titled, Fall Management, dated 7/2017, revealed .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .to minimize the risk of falls . Review of Resident #60's medical record revealed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review showed the resident was readmitted on [DATE], with new [DIAGNOSES REDACTED]. Continued review showed a new [DIAGNOSES REDACTED]. Further review showed a new [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed .Resident #60 had severe cognitive impairment; He required supervision with walking and locomotion on and off the unit . Review of the Quarterly MDS dated [DATE] revealed .Resident #60 had severe cognitive impairment; He required supervision and 1 person physical assistance with walking in the room, in the corridor and locomotion on and off the unit . Review of Resident #60's Fall/Unattended Report dated 7/3/2019 at 11:43 PM revealed .Resident found in (named room number) in supine position, alert mental but slow response observed. No injuries, no skin tear, no bleeding, no bruises observed. B/P (Blood Pressure) was 153/80 RR (Respirations) 24, 02 SAT (Oxygen Saturation) 95% R/A (Room Air) at that time. This nurse called 911 for further evaluation due to L[NAME] (level of consciousness), moaning sounds, clammy skin and pale face observed. Keep resident same position due to safety. Review of the Interdisciplinary Post Fall Review dated 7/3/2019, revealed .Resident #60 fell on [DATE], he was found in a supine position on the floor in another resident's room .the fall was unwitnessed . Review of CT (Computerized [NAME]ography) Report dated 7/4/2019 at 1:42 PM, revealed .There is subtle buckling of the anterior superior endplate of C7 . Review of the POS [REDACTED].Patient is pleasantly confused male, resident of (Named Facility). He was found by staff down on the floor. It was unwitnessed. Patient was unable to provide additional details .In the work-up, he was found to have compression fracture of C7 .C collar (cervical collar (neck brace)) was recommended . Review of Resident #60's Fall report dated 12/23/2019 at 9:00 PM, revealed .Patient was observed by staff on the floor on his left side. Per staff patient ROM (Range of Motion) was performed without discomfort and patient was able to transfer. Per night shift nurse patient started to experience increased pain and was given Tylenol 650 mg (milligrams) with relief. The nurse contact(ed) the MD (Medical Doctor) and an order was obtained for X-ray the left hip . Review of Resident #60's Interdisciplinary Post Fall Review dated 12/24/2019 revealed .the fall was unwitnessed . Review of Resident #60's Comprehensive Care Plan revealed no interventions for supervision with ambulation were added after the MDS assessment dated [DATE], or after the fall on 7/3/2019. During an interview on 2/5/2020 at 4:41 PM, CNA (Certified Nursing Assistant) #4 stated she did remember that Resident #60 came back to the facility with a cervical collar. During continued interview, CNA #4 stated Resident #60 changed dramatically after the fall on 12/23/19. During an Interview on 2/6/2020 at 3:15PM, RN #3 stated Resident #60 was unable to ambulate after the fall on 12/23/2019. Review of the physician orders dated 1/2/2020 revealed Resident #60 was admitted to hospice. During an interview on 2/6/2020 at 2:45 PM, Nurse Practitioner (NP) #1 confirmed Resident #60 had Dementia, was a fall risk and experienced a fall on 7/3/2019, which resulted in a C7 fracture. During further interview, NP #1 stated Resident #60's fall on 12/23/2019, resulted in a Proximal Left [MEDICAL CONDITION]. During continued interview she stated .no recollection of low blood pressures, and his blood pressures at that time ranged from 110/70's - 140's/80. There was no indication the resident had a hypotensive episode prior to the fall on 7/3/2019 . Review of Resident #4's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed Resident #4 was readmitted on [DATE], with new [DIAGNOSES REDACTED]. Continued review revealed a new [DIAGNOSES REDACTED]. Review of the fall risk reports dated 4/10/2019, 4/27/2019, 7/25/2019, 10/7/2019, 10/12/2019, 11/18/2019 and 1/24/2020, revealed Resident #4 was at high risk for falls. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed .Resident #4, is rarely or never understood, walking in the corridor required supervision . Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed .Resident #4, is rarely or never understood, walking in the room and the corridor required supervision . Review of Resident #4's Change in Condition Evaluation dated 10/8/2019, revealed .Summary of observations, evaluation and recommendation Patient was ambulating in the hall and staff heard a loud noise and patiet (patient) was observed on the floor lying face down .Patient was sent to (named hospital) due to patient guarding the Right Lower Extremity (RLE) and [MEDICAL CONDITION] to face . Review of the Quarterly MDS dated [DATE] revealed .Resident #4 is rarely or never understood, walking in room and corridor required supervision and 1 person physical assist . Review of the Interdisciplinary Post Fall Review dated 7/23/2019, revealed .Resident #4 had an unwitnessed fall without injuries . Review of the ED (Emergency Department) Combined Triage and Required Charting dated 10/7/2019 3:05 PM revealed .Patient to ED from (named facility) for unwitnessed fall, per EMS (Emergency Medical Service) Patient was face down, no L[NAME] (loss of consciousness), C-Collar in place per EMS, L (Left) eye swelling .has Dementia . Review of the CT Head WO (without intravenous contrast dye) dated 10/7/2019 at 5:03 PM, revealed .Subarachnoid hemorrhage . Review of Resident #4's hospital ICU (Intensive Care Unit) note dated 10/9/2019 revealed . admitted to the ICU with small traumatic subarachnoid hemorrhage . Review of the Inpatient Clinical Summary Final Report dated 10/10/2019 revealed .Final [DIAGNOSES REDACTED]. Review of Resident # 4's Comprehensive Care Plan revealed no interventions for supervision with ambulation after the fall on 7/23/2019. Review of the Nurse Practitioner progress notes on 10/15/2019 revealed .I did discuss today's changes and events with spouse. She is aware of [MEDICAL CONDITION] activity. Explained this is a common effect from a [MEDICAL CONDITION]. Discussed order from hospital to have hospice evaluate . During an interview on 2/5/2020 at 3:18 PM, Nurse Practitioner (NP) #1 stated, .when he fell , he hit his head real hard which most likely caused the brain bleed .the fall was unwitnessed. (named Resident #4) was taking 2 anticoagulants at the time .there was nothing charted prior to the fall to indicate any neurological changes prior to the fall .(named Resident #4) was not treated for [REDACTED]. She further stated, .according to the hospital records, the bleeding was self-limiting, no neurosurgery was performed, aspirin and [MEDICATION NAME] were discontinued. (Named resident #4) was referred to hospice at that time . During a telephone interview on 2/5/2020 at 9:54 PM, Nurse Practitioner #2 stated, .prior to the fall on 10/7/2019 the resident had no neurological deficits . Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #57's Fall Risk Assessment, dated 12/20/2019, revealed .1-2 falls in the last six months .unable to independently come to a standing position .High risk for falls . Review of Resident #57's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Further review revealed Resident #57 required extensive assistance with 1 person physical assist with transfers, toileting use and personal hygiene. Review of a Nurses Note dated 12/24/2019 revealed .Resident evaluated by this Registered Nurse (RN) #2 following a fall. Per Certified Nurse Assistant (CNA) #2, resident was assisted to the toilet, and was told that she would help the resident back into her wheelchair when she was finished. CNA #2 left the bathroom .Per resident, resident was attempting to get back in her wheelchair off the toilet in the bathroom without assistance when she fell on to the ground on her L (Left) shoulder .resident transported to (named hospital) for concern for injury to left upper arm and shoulder . During an interview on 2/3/2020 at 3:30 PM, Resident #57 stated, she got hurt and pointed to her L arm. Review of Resident #57's interdisciplinary post fall review dated 12/24/2019 revealed .unwitnessed fall .resident was attempting to wipe herself after a bowel movement .resident found on the floor of the bathroom when CNA #2 returned to the room . Review of Resident #57's fall report dated 12/24/2019 revealed .patient tried to stand up to wipe herself from having a bowel movement and fell .gait imbalance .unaware of physical limitations .history of falls .(named CNA #2) was educated per (by) the Unit Manager regarding the importance of staying near the bathroom or outside the door to promote safety while providing privacy . Review of the Emergency Department radiology report dated 12/24/2019 revealed .minimally displaced [MEDICAL CONDITION] proximal humerus . During an interview on 2/4/2020 at 4:11 PM, Licensed Practical Nurse #1 confirmed (CNA #2) left Resident #57 alone in the bathroom on 12/24/2019, and the resident had a fall resulting in a L shoulder fracture. During a telephone interview on 2/4/2020 at 8:39 PM, CNA #2 confirmed she assisted Resident #57 to the bathroom on 12/24/2019 then left her alone while she (CNA #2) left the room and went to the linen cart. During interview on 2/4/2020 at 10:30 PM, the Regional Administrator stated, they (named facility) can't provide one on one (resident supervision continuously by 1 staff ) for dementia residents. An Immediate Action Removal Plan was verified by the surveyors on 2/7/2020 by: 1. The surveyors verified through review of care plans and staff interviews the care plan interventions were implemented for Residents #4, #57 and #60. Resident #4's Care Plan was was updated to reflect staff will offer assistance with ambulation. Resident #57's Care Plan was updated to reflect she required moderate assistance with toileting. Resident #60's Care Plan was updated to include bilateral fall mats when in bed and bed in low position. 2. The surveyors verified all safety interventions were in place for 3 residents (#4, #57 and #60). The surveyors verified the facility's 100% audit of residents who were at risk for falls and reviewed the care plans for the residents at risk. 3. The surveyors reviewed and verified the Fall Prevention and ADL's/Functional Status education and training was completed for the Certified Nursing Assistants who were present (90% of the CNA staff) on 2/6/2020. The remaining 10% will receive education by 2/10/2020. The surveyors verified the facility held an AdHoc/QAPI meeting (an immediate meeting by Administrative staff to address the immediate situation) on 2/5/2020 to include discussion related to fall prevention and care plan implementation. The facility's noncompliance at F-689 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review and interview, the facility failed to implement Abuse and Neglect Prohibition Policy and to provide training to facility and agency staff on abuse recognition, abuse prevention and abuse reporting. This failure resulted in Harm to the residents for prevention of abuse and failure to provide protection from abuse. The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised 8/17, revealed . the facility will train each employee on this policy during orientation, annually, and more often as determined by the facility .The facility will provide training regarding related policies and procedures . Interview with the Director of Nursing (DON) in the conference room on 10/30/17 at 9:30 AM revealed the facility trained 29 of 239 employees in 2017 on Abuse and Neglect prevention as evidenced by document titled .Training Attendance . Continued review revealed the training dates listed were 1/13/17 and 07/31/17. No additional documentation of Abuse and Neglect training were provided for calendar year 2017. Further interview with the DON confirmed the Agency staff were not included in the facility abuse and neglect prevention training. The DON stated .I was told the individual agencies do their own training . Interview with Registered Nurse (RN) #6 on 10/25/2017 at 3:40 PM revealed .Agency staff are not included in Greenhills Rehab orientation or training . Interview with RN #1 revealed .No, I did not get any orientation, I am agency . Interview with the DON on 10/30/17 at 6:10 PM in the conference room confirmed the facility failed to provide training for facility staff and agency staff on abuse and neglect prevention.

Based on facility staffing records, medical record review, facility policy review, observation, and interview, the Administrator failed to maintain safe, trained, and oriented staffing which contributed to neglect, falls, and/or abuse for 10 of 18 residents residing on the 3rd floor of the facility. The Administrator's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for the residents. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Medical record review revealed multiple falls resulting in injury to residents assessed as high risk for falls without interventions to prevent falls from time of admission. Continued review revealed falls were not investigated to determine a cause per facility policy. Further review revealed resident to resident altercations were not reported to the facility Abuse Coordinator, the state, or investigated per facility policy. Observations revealed residents were wearing soiled clothing, wearing the same clothes for consecutive days and were not provided baths/showers, and personal hygiene regularly. Interview with the Administrator with the DON present on 10/24/17 at 6:55 PM in the conference room confirmed the facility had difficulties with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNA's). Continued interview revealed the Administrator stated when she began working at the facility in September, there were at least 20 agency staff working in the facility on a daily basis. Interview with the DON on 10/30/17 at 9:20 AM in the conference confirmed she was not aware of any recent resident to resident altercations on the 3rd floor and there were no current investigations related to abuse in the facility. Interview with Registered Nurse (RN) #5 on 10/30/17 at 3:03 PM in the conference room confirmed she was the Unit Manager on the 3rd floor and was aware of a resident to resident altercation that occurred on 10/4/17. Continued interview revealed the RN stated, I reported it verbally to the Administrator the next day in the clinical stand up meeting. Further interview revealed the RN was not instructed to initiate an investigation by the Administrator. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Further interview confirmed the facility failed to prevent, protect, report and investigate allegations of abuse and the Administrator's failure to prevent, protect, report and investigate the allegations of abuse resulted in harm to the residents. Refer to F-224 K Refer to F-309 K Refer to F-323 K Refer to F-353 K

Based on medical record review and interview, the Medical Director failed in his role/function related to a fall prevention program, protocol or interventions, abuse investigations, and a behavioral monitoring program. This failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for the residents of the facility. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Medical record review revealed multiple falls resulting in injury to residents assessed as high risk for falls without interventions to prevent falls from time of admission. Continued review revealed falls were not investigated to determine a cause per facility policy. Further review revealed resident to resident altercations were not reported to the facility Abuse Coordinator, the State Agency, or investigated per facility policy. Interview with Registered Nurse (RN) #5 on 10/30/17 at 3:03 PM in the conference room confirmed she was the Unit Manager on the 3rd floor and the secured unit. Continued interview confirmed several residents in the secured unit had behaviors of wandering, anxiety, agitation, combativeness, and intrusion into other residents rooms. Further interview confirmed the facility did not have a behavioral management program in place and utilized the services of a Psychiatric Nurse Practitioner twice a week. Telephone interview with the Medical Director (MD) on 10/30/17 at 2:25 PM stated he was aware the facility used multiple agencies to staff the facility and stated, It's a problem in every facility in Davidson County. Continued review revealed the MD was unaware the facility did not have a fall prevention program or protocol or a behavioral health program in place. Further interview revealed the MD stated, I would expect a higher incidents of falls on the secure unit. Maybe it's a little higher than most, and maybe it does have to do with staffing, I don't know. Continued interview confirmed the Medical Director did not make any recommendations to the facility to lessen the incident of falls, or behavioral concerns and stated, It's up to the facility to determine the interventions. Further review revealed the MD was not aware the Care Plans were not individualized to each resident and failed to contain pertinent interventions. He stated, Whatever we're not doing, we will fix it. Continued interview confirmed the Medical Director failed to prevent possible servious injury or harm for the residents by not ensuring protocols for fall prevention, abuse investigations and behavioral monitoring. Refer to F-224 K SQC Refer to F-309 K SQC Refer to F323 K SQC Refer to F327 K SQC Refer to F353 K SQC Refer to F490

Based on facility policy review, medical record review, observation, and interview, the facility's QAPI (Quality Assurance and Performance Improvement) committee failed to recognize inadequate staffing; failed to prevent neglect of residents; failed to prevent abuse of residents; failed to prevent accidents; failed to identify escalating behaviors; and failed to implement an appropriate plan of action to correct the deficient practice. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for residents in the facility. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Review of facility policy, Quality Assurance & Performance Improvement Committee (QAPI), undated revealed, .The QAPI process enables us to better serve our customers through routine, systematic performance evaluation, monitoring, and follow-through. The QAPI process will help .Prioritize high risk, high volume, problem-prone opportunities .Improve/fix opportunities using a Performance Improvement Plan . Review of an Identification of Others at Risk form dated 8/8/17 revealed, .19 residents have been identified that are present in the facility that have had a fall since 6/20/17 .Fall Prevention System not fully implemented . Interview with the Administrator with the Director of Nursing (DON) present on 10/24/17 at 6:55 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with Nurses and Certified Nurse Aides (CNA's). Further interview revealed the facility was trying to hire their own staff but could not compete with agency pay, flexibility of scheduling, and agency staff being paid in advance or daily. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls, or behavioral management program. Further interview confirmed the QAPI Committee failed to prevent neglect, and failed to protect, prevent, report and investigate allegations of abuse. Refer to F-224 K SQC Refer to F-309 K SQC Refer to F-323 K SQC Refer to F-353 K SQC Refer to F490 K Refer to F501 K Refer to F-511 K

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide services to prevent neglect by failure to provide supervision and interventions to prevent falls for 5 residents (#1, #16, #17, #19, #28) of 7 residents reviewed; failed to assess pain for 2 residents (#1, #28) of 7 residents reviewed; failed to provide grooming and showers to 2 residents (#6, #7) failed to provide supervision to prevent ongoing violent behaviors for 2 residents (#20, #22). The resulting failure constituted an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. F224 is Substandard Quality of Care (SQC) The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised 8/2017 revealed, .Each resident has the right to be free from .neglect .To help ensure a resident's right to a safe and healthy environment .Neglect means a failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, ambulatory, occasionally incontinent of urine, and always continent of bowel. She had 1 fall without injury since the prior assessment. Medical record review of Fall Risk Assessments dated 1/9/17, 4/18/17 and 6/26/17 revealed Resident #1 was assessed to be at High Risk for falls. Medical record review of a Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed Resident #1 was at risk for falls with interventions to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Continued review revealed a focus of at risk for pain related to decreased mobility with interventions to administer pain medications prior to treatments and therapy if indicated; anticipate the resident's need for pain relief and respond immediately; evaluate the effectiveness of pain interventions; and provide non-pharmacological interventions: repositioning; support; activities. Medical record review of Nursing Monthly Summaries dated 2/8/17, 3/8/17 and 5/8/17 revealed the resident was oriented to person only and was ambulatory most of the day. Medical record review of a SBAR (Situation, Background, Assessment, Recommendation) Summary and Progress Note dated 6/20/17 at 12:49 PM revealed, .Resident had a fall in hallway, housekeeping services alerted this writer .Resident has a skin tear on right arm and is complaining of right leg pain .Resident is being sent to (emergency room ) for evaluation and treatment . Medical record review of a Nurses Note dated 6/20/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of right lower extremity, pain level, or transferring and positioning information. Medical record review of a hospital History and Physical dated 6/20/17 revealed the resident had a medical history significant for Dementia, had a fall and .reported significant pain in the right lower extremity/right hip .awake, alert, but not oriented .she can follow simple commands, but not consistently .Image(s) (X-Ray) Hip 6/20/2017 (3:53) PM IMPRESSION: RIGHT femoral neck fracture . Continued review revealed the resident underwent [REDACTED]. Medical record review of a Nurse Practitioner (NP) Medical Progress Note dated 6/28/17 revealed, .readmitted .following acute hospitalization for fall with subsequent right femur fracture .She is no longer ambulatory at this time .She is self propelling (wheelchair) around hall, but is very slow and weak .General Appearance .Disheveled, Thin/frail . Medical record review of a NP Medical Progress Note dated 7/6/17 revealed, Pt (patient) requires frequent reorientation to environment and monitoring for falls .Since readmission from hospital, (patient) has been much more lethargic, weak .She is now non-ambulatory and is unable to self propel (wheelchair) due to [MEDICAL CONDITION] and cognitive impairment .General Appearance .Disheveled, Thin/frail .Continue close fall precautions and report any acute injuries . Review of an Incident/Accident Report form dated 8/2/17 at 2:00 PM revealed Resident #1 was found on the floor in the dining room and, .Resident was sitting in dining room after lunch. Got out of wheelchair and tried to walk . Medical record review of a Nurses Note dated 8/2/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of the left lower extremity, transferring, positioning, or activity level of the resident after the fall. Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a NP Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture. (Patient) was recently hospitalized for [REDACTED].according to staff thought she could walk .got up without assistance and fell . No further details of events surrounding fall know by the (Nurse Practitioner) at this time .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .Radiography .Testing Reviewed: Date 8/03/17 Test Results: Left femoral neck fracture .Administration to (evaluate) and investigate falls for any possible cause of recurrent falls and for future fall precautions interventions .(positive) pain during transfer to stretcher . Medical record review of the 8/2017 Medication Administration Record [REDACTED]. Continued review revealed no assessment to the effectiveness of the pain medication and no further assessment of pain to the left hip. Medical record review of a hospital History and Physical Report dated 8/3/17 at 11:11 AM revealed Resident #1 complained of left hip pain status [REDACTED].She underwent an x-ray which revealed a [MEDICAL CONDITION] femoral neck .she will not answer questions or really follow commands .Her urinalysis was felt to be consistent with a urinary tract infection .she is being admitted for further evaluation and treatment .Assessment/Plan [DIAGNOSES REDACTED].Acute UTI (urinary tract infection) . Interview with the NP #2 on 10/24/17 at 2:20 PM in the conference room confirmed she was notified of the fall of Resident #1 on 8/2/17 verbally by staff, but was unable to remember who told her. Continued interview confirmed she ordered an X-ray on 8/2/17. Further interview confirmed she was not notified of the X-ray results that revealed a fracture to Resident #1's left hip until 8/3/17 when she began rounding between 6:30 AM and 7:00 AM and found the results herself. Telephone interview with Registered Nurse (RN) #3 on 10/24/17 at 3:50 PM revealed the nurse was an agency nurse and was caring for Resident #1 when she had falls on 6/20/17 and 8/2/17. Continued interview revealed on 6/20/17 at approximately 12:15 PM the resident was found on the floor in another residents room by Housekeeper (HK) #1 who alerted the RN. Continued interview revealed RN #3 stated, We went down there and she was moaning and groaning. I got vital signs but didn't move her and alerted the Nurse Practitioner. Me and 2 techs assisted her back to bed. The Nurse Practitioner was already on the 3rd floor and she told us to call 911 and send her to the hospital. Further interview with RN #3 regarding the resident's fall on 8/2/17 revealed, It was in the dining room after dinner (lunch). She had oxygen on and was in the wheelchair. I think she tried to get up and walk and fell . She had tried to walk before and hadn't fallen. Continued interview revealed RN #3 could not remember who notified her the resident had fallen and stated, Maybe there was other staff and residents in the dining room. They heard a thump and then she was on the floor on her left side. I called the Nurse Practitioner and she said she'd be right there because there were so many falls on the 3rd floor. Continued interview revealed when asked how the resident was transferred, RN #3 stated, I don't know who did it or how she was transferred, but I had an inkling she had a fracture. Further interview with RN #1 revealed, They are staffed mostly with agency. They are short on techs a lot. I've worked with 3 techs on day shift when we needed 4 or 5. They need more on the dementia unit because they walk all the time. It's poorly staffed. Continued interview with RN #3 confirmed she did not receive any facility orientation prior to or while she worked in the facility. Interview with the Director of Nursing (DON) on 10/24/17 at 6:50 PM in the conference room when asked what the cause of the fall to Resident #1 was on 6/20/17 stated, More than likely a UTI. Continued interview revealed when asked what did the facility do to prevent a future fall the DON stated, We looked at our hydration program to encourage po (by mouth) fluids. Continued interview revealed when asked where was the documentation for the resident, the DON stated, There's not. It was more of a unit wide initiative. Further interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview with the DON when asked what the facility could have done to prevent the second fall on 8/2/17 the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes with her. Interview with the Administrator and the DON on 10/24/17 at 6:55 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNAs). Continued interview revealed the Administrator stated when she began working at the facility in September there were at least 20 agency staff working in the facility on a daily basis. Interview with Housekeeper (HK) #1 on 10/25/17 at 7:55 AM in the 3rd floor dayroom confirmed she found Resident #1 in the doorway of a resident room on 6/20/17. Continued interview revealed HK #1 stated she called for RN #3 and she came out of another resident's room, got a wheelchair, and I picked the resident up by myself under her arms. She was able to stand on her own some, cause the nurse checked her first. Then I sat her down in the wheelchair and the nurse wheeled her back to her room. Continued interview confirmed no other staff members were present or assisted HK #1 or RN #3. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #1 was not capable of using her call light and her Comprehensive Care Plan did not accurately reflect interventions to prevent falls. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to report X-ray results of a fracture to the Physician or Nurse Practitioner for 13 1/2 hours after receiving the x-ray results. Continued interview confirmed the facility failed to evaluate the effectiveness of pain medication administered at 4:49 PM on 8/2/17, and failed to assess for signs and symptoms of pain after that time until the resident was discharged to the hospital on [DATE] at 8:30 AM. Further interview with the DON confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls and the facility failed to prevent neglect for Resident #1. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor of the facility. Medical record review of a Comprehensive Care Plan dated 4/14/16 revealed a focus of .Has had an actual fall with no injury (related to) Unsteady gait, Psychoactive drug use, Poor Balance, Poor communication/comprehension . Continued review revealed the following interventions: 4/14/16 Place frequently used items and call light in reach; Offer/Assist to toilet frequently and as accepted; For no apparent acute injury, determine and address causative factors of the fall; Encourage resident to ask for assistance. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, had no behaviors and required extensive assistance of 2 or more people for bed mobility and transfers, and ambulated in her room only once or twice with assistance of 1 person; was unsteady and only able to stabilize with staff assistance and used a wheelchair for mobility. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Further review revealed the resident had no previous falls. Review of a Quarterly MDS dated [DATE] revealed Resident #16 had behaviors of wandering 1-3 days of the previous 7 days, required extensive assistance of 1 person for bed mobility, ambulation in her room, and locomotion on and off the unit and used a wheelchair for mobility. Continued review revealed the resident had 1 fall with no injury and 2 falls with injury since the previous assessment. Medical record review of Fall Risk Assessments dated 7/11/17 and 10/10/17 revealed the resident was assessed to be at High Risk for falls. Medical record review of interventions on the at-risk plan dated 7/25/16 revealed Add anti-roll back to wheelchair; 8/4/17 Bedroom door to be ajar while patient in room alone. Landing strips to both side of bed; 8/30/17 8/24/17 Seating was adjusted with new cushion for wheelchair in place. Medical record review of an SBAR Summary dated 7/31/17 at 4:02 PM revealed, .found on floor in door hematoma and bleeding noted on forehead . Medical record review revealed no further documentation regarding the resident's fall or care she received. Medical record review of a hospital record dated 7/31/17 at 5:43 PM revealed .soft tissue swelling of the frontal scalp .Acute subcapital right femoral neck fracture . Continued review of a History and Physical revealed, .advanced dementia (nonverbal, mostly gets around with a wheelchair) presented to our (emergency room ) after being found on the floor at her nursing home. She had a laceration to her forehead .The (emergency room ) physician noticed her right leg was shorter than her left, and a hip xray showed a [MEDICAL CONDITION]. The patient is being admitted for further evaluation .laceration to forehead with steri strips (skin closure fore small cuts and wounds) in place .right leg short and externally rotated . Medical record review of a Medical Progress Note dated 8/2/17 revealed, .Re-admission assessment .seen .following acute hospitalization of fall with [MEDICAL CONDITION] and suspected right [MEDICAL CONDITION] .no surgical intervention was performed .non-ambulatory and sitting up in (wheelchair) .continues to pick at [MEDICAL CONDITION] and has caused increased bleeding .Appearance .Disheveled .large open shallow abrasion to forehead with active bleeding .monitor for falls .Administrative staff to assure appropriate fall prevention interventions are in place and that (patient) is in a safe environment . Medical record review of a SBAR Summary dated 8/24/17 at 7:17 PM revealed, .Resident found on floor in right lateral position (patient) has skin tear on right eyebrow area .Resident usually has wandering on hallway with (wheelchair) sometimes (patient) fall on floor with injury or without injury (patient) need special (wheelchair) for safety .skin tear site dressing done with steri strips . Medical record review of a SBAR Summary dated 9/6/17 at 11:57 AM revealed, .alert with some confusion was called to hallway noticed the resident was sitting on the floor on buttocks noticed blood from forehead clean with (normal saline) and apply bandage . Medical record review of a NP Medical Progress Note dated 9/11/17 revealed, .seen for (evaluation) and treatment of [REDACTED].indicating (positive) infection .labs obtained following recurrent fall with reopening of forehead abrasion .increased restlessness and anxiousness .Bruising and skin tears to upper extremities .Remains at a high risk of falls. Will hopefully improve with treatment of [REDACTED]. Medical record review of a SBAR Summary dated 9/27/17 at 3:01 PM revealed, .fall no injury . Continued review revealed no further documentation regarding the fall. Medical record review of a SBAR Summary dated 10/4/17 at 8:07 PM revealed, .Resident has a habit (holding others {wheelchair} or clothes) (patient) grasp fistful of (Resident #20's wheelchair) so (Resident #20) upset and smacking her face . Medical record review of a Nurses Note dated 10/6/17 at 8:53 PM revealed, .Resident up in (wheelchair) and wandering .observed redness on face (skin) almost disappeared . Observation of Resident #16 on 10/25/17 at 8:30 AM in the 3rd floor dining room revealed she was seated in a wheelchair with a cushion on it at a table waiting for breakfast with 3 other residents. Continued observation revealed she was alert, calm and nonverbal. Continued observation revealed no anti-roll back device to her wheelchair. Interview with the Administrator and the DON on 10/25/17 at 6:55 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNAs). Continued interview revealed the Administrator stated when she began working at the facility in September there were at least 20 agency staff working in the facility on a daily basis. Interview with the DON on 10/30/17 at 9:20 AM in the conference confirmed she was not aware of a resident to resident altercation between Resident #16 and Resident #20. Continued interview confirmed the facility failed to report allegations of abuse. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the resident was severely cognitively impaired and incapable of using a call light, unable to ask for assistance, was always incontinent of urine and unable to determine when to toilet. Continued interview revealed the MDS coordinator did not know what the intervention to continue interventions on the at-risk plan meant, and could not determine why changing the cushion to the resident's wheelchair aided in a fall prevention. Further interview confirmed the interventions to prevent falls for the resident were not applicable and/or were not specific for the type of falls the resident experienced. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to investigate the cause of multiple falls to the resident and place specific, individualized, interventions on the Care Plan to prevent future falls. Continued interview revealed when asked what the 'interventions on the at risk plan' were the DON stated, I have no idea. Further interview confirmed the resident did not have an anti-roll back device for her wheelchair, and the facility had no fall prevention program or a fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview with the DON when asked what the facility could have done to prevent multiple falls for Resident #16, the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes. Further interview with the DON confirmed the facility failed to investigate the cause for multiple falls to the resident and failed to provide appropriate fall interventions to prevent accidents resulting in a forehead hematoma, a right femoral neck fracture, a right eyebrow laceration and multiple bruises to the resident. Continued interview confrmed the facility failed to prevent neglect to Resident #16. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secure unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated MDS dated [DATE] revealed the resident was moderately cognitively impaired and had behaviors not directed to others for 1-3 days of the look back period. The resident required supervision for ambulation in his room and had only ambulated in the hallway 1or 2 times during the look back period. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of the Initial Care Plan dated 9/1/17 did not include safety or fall risk as a focus or potential problem and no interventions to prevent a fall. Medical record review of a SBAR dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to a hospital. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline admitted in May with heart failure exacerbation .started on .[MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICAL CONDITION] . Continued review revealed a past surgical history of a permanent pacemaker with transvenous [MEDICATION NAME]; [MEDICAL CONDITION] and an active [DIAGNOSES REDACTED]. Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) [MEDICAL CONDITION] to flanks . Continued review revealed, .he is chronically hypotensive related to [MEDICAL CONDITION] . Medical record review of a Care Plan Note dated 9/20/17 revealed, .(Interdisciplinary Team) review of falls .sent out post fall and readmitted .has history of cardiac issues .patient to be out (in) day area as (frequently) as possible . Medical record review of the Comprehensive Care Plan dated 9/22/17 revealed a focus of [MEDICAL CONDITION] with interventions to check breath sounds and observe/document labored breathing; give cardiac medications as ordered; and observe input and output. Continued review revealed no identification or care of an ICD was noted on the Care Plan. Continued review revealed a focus dated 9/22/17 for Hypertension with interventions to educate the resident regarding exercise, limiting salt intake and medication and diet compliance; Give antihypertensive medications as ordered and observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate, observe and document any [MEDICAL CONDITION] and notify MD (Medical Doctor). Continued review revealed a focus dated 10/17/17 for At risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs with interventions as follows: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate non skid footwear when ambulating, transferring, or mobilizing in (wheelchair). Continued review revealed on 10/25/17 .late entry from fall on 9-7-17 patient sent out to ER (emergency room ) returned on 9-19-17 with noted changes [MEDICAL CONDITION](hypertension) medication . Continued review revealed no further interventions to place Resident in the day area to prevent future falls, or any interventions to monitor vital signs prior to administration of antihypertensive medication. Medical record review of the MAR (Medication Administration Record) dated 9/2017 revealed an order for [REDACTED]. Further review revealed no documentation of a heart rate or blood pressure prior to administration of either medication. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #17 was a high fall risk and failed to identify Resident #17's increased risk for falls with interventions on the initial Care Plan dated 9/1/17. Further interview with the MDS Coordinator when asked if identification and care for an ICD was included on the Comprehensive Care Plan stated, No, but we should have been monitoring it. We missed it. Continued interview confirmed the facility failed to identify the resident as at risk for actual falls, failed to provide interventions to prevent a fall, failed to provide an intervention after an actual fall, and failed to provide interventions for monitoring blood pressure and heart rate with administration of cardiac medications for Resident #17. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to provide parameters for appropriate heart rate and or blood pressure values prior to the administration of [MEDICATION NAME] and [MEDICATION NAME] and failed to check and document a heart rate and blood pressure prior to administration of the medications to Resident #17. Continued interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview confirmed the facility failed to investigate the cause of the fall and failed to prevent neglect to Resident #17. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged to hospital on [DATE] with [DIAGNOSES REDACTED].#2, History of Falling, Head Injury, Weakness, Hypertension, Anorexia, Lack of Coordination, and Difficulty Walking. Medical record review of an Admission MDS dated [DATE] revealed the resident was cognitively intact, required extensive assistance of 1 person for bed mobility, transfers, and ambulation in her room. Continued review revealed she was not steady on her feet and was only able to stabilize with staff assistance. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of an Initial Care Plan dated 9/26/17 revealed a focus of Safety/Fall Risk related to History of Falls and decreased safety awareness with interventions to observe for placement and function of devices per facility protocols; and initiate safety checks as indicated. Medical record review of a Care Conference Note date 9/28/17 revealed, .Resident is a high fall risk . Medical record review of a SBAR Summary dated 10/8/17 at 5:19 AM revealed the resident had a fall and, .resident was getting up from bed to go walk to rest room when she slipped . Medical record review revealed no further documentation regarding the fall was present. Medical record review of a Nurses Note dated 10/15/17 at 9:00 PM revealed, .notified .while assisting patient to the commode, the patient sat down quickly on her own, and bumped her back against the rail next to the commode. At the time the patient stated she hit her head, but (CNA) denies witnessing patient hit her head .will notify the MD if any acute (symptoms) observed or patient expressess pain . Medical record review of a SBAR Summary dated 10/16/17 at 12:13 AM revealed, .fell (complained of) (left) hip pain .resident was transferring self with walker to restroom, staff heard loud noise, enter room observe resident lying on floor on back in front of toilet, stated she hit her head, staff assisted resident up and to bed. (Complained of) pain to (left) hip while walking, notified MD (Medcial Doctor) on call orders received to send to hospital for (evaluation) . Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the Initial Care Plan for Resident #19 had no interventions to prevent falls as the resident did not have any medical devices and there was no protocol for safety checks. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed Resident #19 was still in the hospital due to the fall on 10/16/17 with a left [MEDICAL CONDITION]. Continued interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Further interview with the DON confirmed the facility failed to prevent falls resulting in a fracture, and failed to prevent neglect for Resident #19. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a History and Physical dated 9/13/17 revealed, .She apparently fell the other weekend she has had ongoing pain and discomfort in her left knee .and significant swelling . Medical record review of an Admission MDS dated [DATE] revealed the resident had no previous falls in the last six months prior to admission to the facility. Medical record review of a SBAR Summary dated 10/6/17 revealed, .10/5/17 Resident was found on the floor .Resident was sent to (hospital) as requested by family . Continued reveiw revealed the resident was evaluated by the Emergency Department and discharged with [DIAGNOSES REDACTED]. Medical record review of an Interdisciplinary (IDT) Post Fall Review dated 10/20/17 revealed Resident #28 fell and was found in her room. Continued review revealed the fall was unwitnessed and no injuries documented. Further review revealed no assessment of neurological assessment was performed after the fall. Medical record review of a Comprehensive Care Plan dated 9/25/17 revealed interventions were not initiated until 10/25/17 after the resident sustai(TRUNCATED)

Based on facility policy review, medical record review, observation, and interview, the facility failed to investigate allegations of abuse for 2 residents (#2, #16) of 4 residents reviewed and failed to report these allegations to the State Agency. This failure resulted in Harm for Residents #2 and #16. The findings included: Review of facility policy, Abuse and Neglect Prohibition revised ,[DATE] Section Prevention revealed .Residents, families, and staff will be able to report incidents and concerns without fear of retribution .Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin .The facility will protect residents from harm during the investigation .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and adult protective services, in accordance with Federal and State law through established procedures . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview of Resident #2 on [DATE] at 9:00 AM revealed I almost died last night, the man behind the wooden part tried to kill me, he hit me here, and grabbed my arm, I think he is from another town. Resident #2 had visible bruising on her left forearm on lateral side. Resident #2 touched the left side of her face and stated, he hit me here. Resident #2 showed surveyor the inside of her mouth and stated It hurts in here. Medical record review of a Nurses Note for Resident #2 dated [DATE] at 11:17 AM revealed .Resident stay(ed) in the dining room patient stated that I still have anxiety r/t (related to) release of fire extinguisher, patient has bruises on arm . Medical record review of a Nurses Note dated [DATE] at 9:10 AM revealed, .Patient reported that she was hit on her left upper arm and left forearm, and side of face. Bruising noted to left arm and slight swelling to left side of face. Patient denies any pain at this time. She also stated the man that hit her was from another state. She also stated the patient was in the wooden part of the floor. (Nurse Practioner) notified today . Interview with Registered Nurse (RN) #2 at 10:50 AM on the telephone revealed she was informed of Resident #22 grabbing the arm of Resident #2. RN #2 stated One more time he had those behaviors, he tried to hit Resident #21 in the hallway. Further interview revealed Resident #22 picked up the plastic planter and attempted to hit other residents. RN #2 was asked if she reported the assault to the administrator stated No, I did not. Medical record review of a facility investigation dated [DATE] at 1:00 AM written by LPN #3 revealed .Patient was yelling, this nurse went to her room (Resident #2) and a male patient (#22) was in her room. She states that he was trying to kill her, she states that he grabbed her left arm, and she has a bruise on her left arm . Interview with RN #5 on [DATE] at 3:00 PM in the conference room revealed Resident #2 was grabbed and hit by Resident #22 around 1:15 AM in room [ROOM NUMBER]. RN #5 reported LPN #3 informed her of the incident. Further interview revealed Resident #22 was transferred to the third floor due to elopement behavior. RN #5 stated He has tried to hit her before; he is only up here because of his exiting behavior. RN #5 stated (LPN #3) has called the family and completed the incident report. RN #5 stated Yes, I was made aware of the incident at 7:50 AM on [DATE], no I have not reported it. Further interview with RN #5 revealed These patients are a little different up here with dementia. When asked to name the 7 types of abuse RN #5 stated No, I can't name them, I have it up in my office. Interview with the Director of Nursing (DON) on [DATE] at 9:30 AM in the conference room confirmed that she was made aware of an incident. The DON stated I was here around 2:00 AM, and helped evacuate all the residents on the secured unit while we cleaned the hall and rooms; all beds had to be changed from the powder in the fire extinguishers. I was told a resident pulled the pin and sprayed all the powder in the hallway. When asked who the resident was the DON stated I am not sure I think it was a fairly new resident. I think he might have [MEDICAL CONDITIONS]. Continued interview with the DON revealed she did not know about the incident with Resident #2 and Resident #22. Later interview with DON on [DATE] at 6:30 PM confirmed she was made aware of Resident #2 and Resident #22 altercations in Resident #2's room when she arrived on the unit at 2:00 AM. Further interview with the DON revealed when she was asked if she reported resident to resident abuse, she stated No. I have been told not to report it. When asked if she could name the 7 types of abuse the DON stated No I can not, I will have to look at the policy, I really am trying. When asked if this incident was reported to the State Agency the DON stated, No, it has not been reported. Interview with the DON on [DATE] at 5:50 PM in the conference room confirmed the facility failed to report the abuse to the State Agency and to protect Resident #2 during the investigation. Medical record review, observations, and interviews revealed the facility failed to thoroughly investigate the physical abuse incident between Resident #2 and Resident #22 involving physicial abuse. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, exhibited behaviors of wandering ,[DATE] days of the previous 7 days, and used a wheelchair for mobility. Medical record review of a SBAR Summary dated [DATE] at 8:07 PM revealed, .Resident has a habit (holding others {wheelchair} or clothes) (patient) grasp fistful of (Resident #20's wheelchair) so (Resident #20) upset and smacking her face . Medical record review of a Nurses Note dated [DATE] at 8:53 PM revealed, .Resident up in (wheelchair) and wandering .observed face, skin redness almost disappeared . Interview with the DON on [DATE] at 9:20 AM in the conference room confirmed she was not aware of a resident to resident altercation on [DATE] between Resident #16 and Resident #20. Continued interview confirmed the facility failed to report allegations of abuse to the State Agency. Telephone interview with RN #2 on [DATE] at 10:20 AM confirmed she was caring for Resident #16 on [DATE] on the 3:00 PM-11:00 PM shift and was at the nurse's station on the 3rd floor when someone told her Resident #20 had hit Resident #16. Continued interview revealed the RN was unable to remember who reported the incident to her. Continued interview confirmed the nurse separated the 2 residents and noted Resident #16 had a red line on the left side of her face below the eye which was present for at least 2 days and confirmed she wrote the SBAR Summary. Continued interview with RN #2 when asked if she had been trained in abuse prevention stated, Oh sure. I've had several in-services, the last one was less than a month. Continued interview revealed when asked if the nurse thought it was abuse, the RN stated, No. I didn't see it as abuse. It's a secure unit with combative patients. This wasn't the first time (Resident #20) was combative. I've seen this many times. The Nurse Practitioner gave orders for meds (medicines) or sent them to the hospital so it's behaviors. Continued interview with RN #2 when asked if she reported the resident to resident altercation to the Abuse Coordinator stated, We report to the Unit Manager and she reports to the DON. I document on the SBAR so they know. No. I did not notify the Administrator. Interview with RN #5 on [DATE] at 3:03 PM in the conference room confirmed she was the Unit Manager on the 3rd floor and was aware of a resident to resident altercation that occurred on [DATE]. Continued interview revealed the RN stated, I reported it verbally to the Administrator the next day in the clinical stand up meeting. Further interview revealed the RN was not instructed to initiate an investigation by the Administrator. Interview with the DON on [DATE] at 6:40 PM in the conference room confirmed the facility failed to investigate allegations of abuse to Resident #16 and failed to report abuse to the State Agency. The facility's failure resulted in Harm to Residents #2 and #16.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide care and services for the resident's highest practicable well being by failure to assess the need for pain medication after a fall resulting in a [MEDICAL CONDITION] to1 resident (#1) and prior to removal of embedded sutures to 1 resident (#28) of 6 residents reviewed for pain; failure to monitor blood pressure and heart rate prior to administration of cardiac medications for 1 resident (#17) of 28 residents reviewed; and failure to assess and monitor behaviors for 2 residents (#20, #22) of 4 residents reviewed with behaviors. The resulting failure constituted an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. F-309 is Substandard Quality of Care (SQC). The findings included: Review of facility policy, Resident Rights, revised 2/2017 revealed, .Facility staff will .care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . Review of facility policy, Comprehensive Care Plan, revised 8/2017 revealed, .The .facility .must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .and to attempt to manage risk factors . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, ambulatory, occasionally incontinent of urine, and always continent of bowel. She had 1 fall without injury since the prior assessment. Review of an Incident/Accident Report form dated 8/2/17 at 2:00 PM revealed Resident #1 was found on the floor in the dining room, .Resident was sitting in dining room after lunch. Got out of wheelchair and tried to walk . Medical record review of a Nurses Note dated 8/2/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of the left lower extremity, transferring, positioning, or activity level of the resident after the fall. Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a Medical Progress Note dated 8/3/17 revealed, .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) .(positive) pain during transfer to stretcher . Medical record review of the Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed a focus of at risk for pain related to decreased mobility with interventions to administer pain medications prior to treatments and therapy if indicated; anticipate the resident's need for pain relief and respond immediately; evaluate the effectiveness of pain interventions; provide non-pharmacological interventions: repositioning; support; activities. Medical record review of an 8/2017 Medicaton Administration Record (MAR) revealed orders for [MEDICATION NAME] tablet 325 mg (milligrams). Give 2 tablets by mouth every 4 hours as needed for pain; and [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Continued review revealed [MEDICATION NAME] was administered to the resident on 8/2/17 at 4:49 PM for left hip pain rated a 5/10. Further review revealed no documentation of the effectiveness of the pain medication, no further assessment of pain to the left hip was present, and no further pain medication was administered to the resident while in the facility. Interview with the Director of Nursing (DON) on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to evaluate the effectiveness of pain medication administered at 4:49 PM on 8/2/17 and failed to assess for signs and symptoms of pain after that time until Resident #1 was discharged to the hospital on [DATE] at 8:30 AM. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On admission to the facility Resident #28 was ordered [MEDICATION NAME] and Tylenol for pain. Medical record review of the Nursing Admission Data Collection document completed by Licensed Practical Nurse (LPN) #8 on 9/20/17 revealed no documentation of the left knee surgical incision and no documentation of sutures. Review of Nursing Daily Skilled Charting completed by LPN #9 on 9/27/17 revealed no documentation of the left knee surgical incision or sutures. Medical record review of Nurse Practioner (NP) #2 Physical Exams dated 9/21/17, 9/22/17, 10/4/17, 10/9/17, 10/17/17, 10/23/2017 10/31/2017 revealed history of present illness: .Surgical debridement . Continued review revealed no documentation of sutures. Interview with NP #2 on 10/31/17 in the conference room, when asked if she saw sutures present on exam stated, .it looked like a hair sticking out . Interview with LPN #10 on 10/31/17 in the conference room, revealed she was not aware of any sutures until 10/24/17. Telephone interview with Resident #28's insurance company nurse on 10/31/17 revealed she was visiting the resident on 10/24/17 at the facility when she was asked to look at the resident's knee by a family member who told the nurse Resident #28's knee was hurting. Continued interview with the nurse revealed, she had four stitches and they were embedded into her skin, and about 2 mm (millimeters) were sticking out of one of the stitches. Continued interview revealed the nurse stated, They should have come out a long time ago. Further interview revealed the insurance nurse reported the embedded sutures to the Charge Nurse. Medical record review of a Wound Note 10/24/17 revealed, .Total of 4 stitches removed. 2 on medial (inner) side of left knee and 2 on lateral (outer) side of left knee Sites cleaned and left open to air . Continued review revealed LPN #10 removed the first three sutures and then asked NP #2 to remove the last suture. NP #2 confirmed during interview on 10/31/17 in the conference room she removed one suture and LPN #10 removed three sutures on 10/24/17. Interview with Minimum Data Set (MDS) Coordinator #2 on 10/31/17 confirmed the MDS and the Nursing assessments were inaccurate and did not reflect the presence of the sutures for Resident #28. Further interview revealed the care plan was not updated after the residents first fall. Medical record review of the October 2017 Medication Administration Record [REDACTED]. Medical record review of the Care Plan dated 10/3/17 revealed .Administer pain medication prior to treatments and therapy if indicated .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Situation, Background, Assessment. Recommendation, (SBAR) Summary dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to a hospital. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline admitted in May with heart failure exacerbation .started on .[MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICAL CONDITION] . Continued review revealed a past surgical history of a permanent pacemaker with transvenous [MEDICATION NAME]; [MEDICAL CONDITION] and an active [DIAGNOSES REDACTED]. Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) [MEDICAL CONDITION] to flanks . Continued review revealed, .he is chronically hypotensive related to [MEDICAL CONDITION] . Medical record review of the Comprehensive Care Plan dated 9/22/17 revealed a focus of [MEDICAL CONDITION] with interventions to check breath sounds and observe/document labored breathing; give cardiac medications as ordered; and observe input and output. Continued review revealed no identification or care of an ICD was noted on the Care Plan. Continued review revealed a focus dated 9/22/17 for Hypertension with interventions to educate the resident regarding exercise, limiting salt intake and medication and diet compliance; Give antihypertensive medications as ordered and observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate, observe and document any [MEDICAL CONDITION] and notify MD (Medical Doctor). Continued review revealed on 10/25/17 .late entry from fall on 9-7-17 patient sent out to ER (emergency room ) returned on 9-19-17 with noted changes [MEDICAL CONDITION](hypertension) medication . Continued review revealed no further interventions to monitor vital signs prior to administration of antihypertensive medication. Medical record review of the MAR indicated [REDACTED]. Continued review revealed no parameters were given when to hold/or administer the medications. Further review revealed no documentation of a heart rate or blood pressure prior to administration of either medication. Interview with the MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed when asked if identification and care for an ICD was included on the comprehensive care plan stated, No, but we should have been monitoring it. We missed it. Continued interview confirmed the facility failed to provide interventions for monitoring blood pressure and heart rate prior to administration of cardiac medications to Resident #17. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to provide parameters for appropriate heart rate and or blood pressure values prior to the administration of [MEDICATION NAME] and [MEDICATION NAME] and failed to check and document a heart rate and blood pressure prior to administration of the medications to the resident. Continued interview confirmed the facility failed to provide care and services for Resident #17's highest practicable well-being. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and 9/14/17, and was discharged to a psychiatric facility on 10/9/17 with [DIAGNOSES REDACTED]. Medical record review of a Discharge Return Anticipated MDS dated [DATE] revealed the resident was severely cognitively impaired and had behaviors of inattention, physical behaviors directed to others, and wandering. Continued review revealed she received antipsychotic, antianxiety and antidepressant medications. Medical record review of the Comphrensive Care Plan dated 4/22/16 revealed the following focus: (1) Receives antipsychotic medications related to dementia with behavior management; (2) Receives anti-anxiety medications as needed related to anxiety and agitation. Continued review revealed interventions included medication administration and monitoring for side effects and effectiveness of the medications. Further review revealed the Care Plan did not contain any non-pharmacological interventions and did not identify behaviors as a problem with interventions to address the resident's documented behaviors. Medical record review of a SBAR Summary dated 6/5/17 revealed Resident #20, .increased confusion and combative disorder observed .wandering everywhere, (patient) opened break room, linen room .stated that 'I have to get out of here. I will go home. If somebody touches me I will kill them' .kicking with agitation .transfer to hospital . Medical record review of a SBAR Summary dated 6/11/17 revealed, .Resident returned from hospital on [DATE] (with) same problems .lunch time she opened door and suddenly threw the food toward staff .when staff trying to control her behavior she hit, scratched staff and yelling out. After closed door she threw the food tray on the floor . Medical record review of a Behavior Note dated 7/26/17 revealed, .increasing agitation this pm. combative .(continues) back and forth between room & nurses station . Medical record review of a Behavior Note dated 8/4/17 revealed, .wandering hallway sometimes .entering other residents' room, (patient) has agitation. At 6 pm .in room and stood up from (wheelchair) (knocking on) window and stated that 'I have to get out of here' . Medical record review of a SBAR Summary dated 8/7/17 revealed, .Resident has been having psychiatric behavior recently pt (patient) (with) increased agitation, self-harming and others harming behavior, wandering kicking toward staff, verbally aggressive, restlessness noted . Medical record review of a Behavior Note dated 8/18/17 revealed, .Resident returned from hospital still pt has confusion, wandering, agitation observed pt trying to use elevator for get(ting) out of here and lay (laid) down in front of elevator . Medical record review of a SBAR Summary dated 8/24/17 revealed, .Resident has been having agitation, combative disorder, suicidal idea so multiple times pt transferred to psychiatric hospital. Today pt has significant behavior observed pt trying to jumping (jump) toward window for suicide and keeping razor to her abdomen also pt crying all day long . Medical record review of a Nurses Note dated 10/9/17 revealed, .Pt rolling around day room in (wheelchair) rolling up to pt striking at another pt. Pt rolling around reaching and try(ing) to hit at other residents. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the resident's Care Plan did not address Resident #17's ongoing behaviors or develop interventions to care for the resident. Continued interview revealed the MDS Coordinator stated, Social Services does behavior Care Plans and it should have been in there. Interview with the DON on 10/30/17 at 6:40 PM in the conference room confirmed the facility failed to implement a Behavioral Care Plan for Resident #20 and the facility failed to provide the care and services required to meet the highest practicable well being and needs of the resident. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Behavior Note for Resident #22 written by LPN #5 dated 10/05/17 at 11:09 PM revealed .7:00PM (patient) became agitated. Went into a (resident's) room [ROOM NUMBER] and removed several of (the) blinds and carried (them) down (the) hall. Able to redirect but for short period. Attempted several times to get out of unit door. Patient later took and threw empty bucket. Able to be redirected. [MEDICATION NAME] administered with helpful results rendered. Patient put (back) to bed . Medical record review of a Care Conference Note written by Registered Nurse (RN) #5 dated 10/16/17 at 11:41 AM revealed .IDT (interdisciplinary team) in to discuss resident with son and daughter-n-law. Resident experienced a decline upon moving to third floor. Resident experiences many ups and downs with his medical/physical condition. Resident is doing better today with therapy. Family reported it was that way at home . Medical record review of a SBAR Summary by RN #4 dated 10/22/17 at 1:34PM revealed .Patient agitated. Additional Nursing Notes as applicable: Family health care agent notified at 11:00 AM on 10/22/17. Primary Care Clinician Notified: Nurse Practioner at 11:00 AM on 10/22/17 . Medical record review of a SBAR Summary dated 10/26/17 at 10:56 PM by LPN #4 revealed .agitated told son 'I want to go home' roaming this shift . Medical record review of a SBAR Summary for Resident #22 dated 10/27/17 3:38AM SBAR summary revealed .Resident is agitated , for no apparent reason. He has an long object in his hand, swinging it at staff and one of the residents. He grabbed a fire extinguisher off of the wall and began to spray it at me and a CNT (Certified Nurse Technician). We were unable to get the extinguisher from him. MD (Medical Doctor) was notified and gave order to send resident out for further evaluation, residents son was notified, as well as emergency room department. Resident was transferred via 911 ambulance service at 1:30AM . Interview with RN #2 at 10:50 AM by telephone with two Surveyors revealed she was informed of Resident #22 grabbing the arm of Resident #2. RN #2 stated .LPN #7 told me about it . RN #2 stated .One more time he have (had) those behaviors, he tried to hit resident in the hallway . Further interview revealed Resident #22 picked up the plastic planter and attempted to hit other residents. RN #2 was asked if she reported the assault and stated .no, I did not . Further medical record review revealed incident/accident report dated 10/27/17 at 1:00 AM written by LPN #3 revealed .Patient was yelling, this nurse went to her room and a male patient was in her room. She states that he was trying to kill her, she states that he grabbed her left arm, and she has a bruise on her left arm . Interview with RN #5 on 10/30/17 at 3:00 PM in the conference room revealed Resident #2 was grabbed and hit by Resident #22 around 1:15AM in Resident #7's room. RN #5 reported LPN #3 informed her of the .incident . Further interview revealed Resident #22 was transferred to the third floor due to elopement behavior. RN #5 stated .He has tried to hit her before; he is only up here because of his exiting behavior . Medical record review of the Psychiatric (Psych) Diagnostic Evaluation performed by Nurse Practitioner #2 dated, 9/11/17, .On exam patient is impulsive, anxious, and confused .9/18/17 .Psych visit after med changes last week for agitation, wandering, increased confusion and questionable [MEDICAL CONDITION] .9/29/17 .Increased confusion intermittently with negative urinanalysis (U/A) .10/17/17 .[MEDICAL CONDITION], trying to shoot others playfully but also paranoid and aggressive. Trying to get off of floor, took butter knife and tried to unscrew the elevator keypad. Resident #22 was attempting to get out of the secured doors. Verbally and physically aggressive towards other residents and staff members .10/24/17 .Patient reportedly tried to hit another resident with a fairly strong object .He continues to be psychotic with aggression and agitation was difficult to redirect. Patient threatening towards staff at times especially when they attempt to redirect . Interview with NP #1 on 10/30/17 at 10:40 AM revealed she was made aware of the incident with Resident #22 on 10/30/2017. NP #1 stated .Resident #22 was moved to the 3rd floor due to possible elopement. His son just doesn't get it, He tried to shoot at people with a plastic plant bottle, and tried to hit Resident # 21. I thought he might have a UTI so I sent his urine off . ANP confirmed the quality of care Resident is receiving on this secured unit was lacking in .consistency, I think it could be better with different staff, I know these residents, and when I only come twice a week I rely on the staff to inform me of changes . Medical record review revealed Minimum Data Set (MDS) assessments for Resident #22 dated 09/15/17, 9/22/17, 10/06/17, and 10/27/17, revealed Behavioral Symptom-Presence with Frequency and Physical behaviors directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) Behavior not exhibited . Based on medical record review, observation, and interview, the facility failed to protect Resident #2 from abuse by Resident #22. Further interview with the DON on 10/31/17 at 1:50 PM in the conference room confirmed the facility failed to investigate report and protect residents from physical abuse. Refer F224 K SQC

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide supervision and interventions to prevent accidents resulting in falls for 5 residents (#1, #16, #17, #19, #28) of 7 residents reviewed; Resident #1 sustained 2 hip fractures. The resulting failure constituted an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. F323 is Substandard Quality of Care (SQC) The findings included: Review of facility policy, Fall Management, revised 7/2017 revealed, .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs .to minimize the risk for falls .The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review .When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring .The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the Care Plan and Progress Notes .The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall .The Care Plan will be reviewed and/or revised as indicated .The At Risk Review committee members will review residents with falls for documentation, compliance, and interventions on a weekly basis . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secure unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, ambulatory, occasionally incontinent of urine, and always continent of bowel, and had 1 fall without injury since the prior assessment. Medical record review of Fall Risk Assessments dated 1/9/17, 4/18/17, and 6/26/17, revealed Resident #1 was assessed to be at High Risk for falls. Medical record review of a Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed a focus of at risk for falls with interventions to anticipate and meet the resident's needs, and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Medical record review of Nursing Monthly Summaries dated 2/8/17, 3/8/17 and 5/8/17 revealed the resident was oriented to person only, and was ambulatory most of the day. Medical record review of a SBAR (Situation, Background, Assessment, Recommendation) Summary dated 6/20/17 at 12:49 PM revealed, .Resident had a fall in (the) hallway, housekeeping services alerted this writer .Resident has a skin tear on right arm and is complaining of right leg pain .Resident is being sent to (emergency room ) for evaluation and treatment . Medical record review of a Nurses Note dated 6/20/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of right lower extremity, pain level, or transferring and positioning information. Medical record review of a hospital History and Physical dated 6/20/17 revealed the resident had a medical history significant for Dementia, had a fall and .reported significant pain with the right lower extremity/right hip .awake, alert, but not oriented .she can follow simple commands, but not consistently .Image(s) (X-Ray) Hip 06/20/2017 (3:53) PM IMPRESSION: RIGHT femoral neck fracture . Continued review revealed the resident underwent [REDACTED]. Medical record review of a Medical Progress Note dated 6/28/17 revealed the visit type was readmission/post hospital discharge review. Continued review revealed, .readmitted .following acute hospitalization for fall with subsequent right femur fracture .She is no longer ambulatory at this time .She is self-propelling (wheelchair) around hall, but is very slow and weak .General Appearance .Disheveled, Thin/frail . Medical record review of a Medical Progress Note dated 7/6/17 revealed, Pt (patient) requires frequent re-orientation to environment and monitoring for falls .Since readmission from hospital, (patient) has been much more lethargic, weak .She is now non-ambulatory and is unable to self-propel (wheelchair) due to fractured hip and cognitive impairment .General Appearance .Disheveled, Thin/frail .Continue close fall precautions and report any acute injuries . Review of an Incident/Accident Report form dated 8/2/17 at 2:00 PM revealed Resident #1 was found on the floor in the dining room and, .Resident was sitting in dining room after lunch. Got out of wheelchair and tried to walk . Medical record review of a Nurse's Note dated 8/2/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of the left lower extremity, transferring, positioning, or activity level of the resident after the fall. Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Medical record review of a Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .Radiography .Testing Reviewed: Date 8/03/17 Test Results: Left femoral neck fracture .Administration to (evaluate) and investigate falls for any possible cause of recurrent falls and for future fall precautions interventions . Medical record review of a Hospital History and Physical dated 8/3/17 at 11:11 AM, Resident #1 complained of left hip pain status [REDACTED].She underwent an x-ray which revealed a fracture of the left femoral neck .she will not answer questions or really follow commands .Her urinalysis was felt to be consistent with a urinary tract infection .she is being admitted for further evaluation and treatment .Assessment/Plan [DIAGNOSES REDACTED].Acute UTI (urinary tract infection) . Telephone interview with Registered Nurse (RN) #3 on 10/24/17 at 3:50 PM revealed the Nurse was an Agency Nurse and was caring for Resident #1 when she had falls on 6/20/17 and 8/2/17. Continued interview revealed on 6/20/17 at approximately 12:15 PM the resident was found on the floor in another resident's room by Housekeeper (HK) #1 who alerted the RN. Continued interview revealed RN #3 stated, We went down there and she was moaning and groaning. I got vital signs but didn't move her and alerted the Nurse Practitioner. Me and 2 techs assisted her back to bed. The Nurse Practitioner was already on the 3rd floor and she told us to call 911 and send her to the hospital. Further interview with the Nurse regarding the resident's fall on 8/2/17 revealed, It was in the dining room after dinner (lunch). She had oxygen on and was in the wheelchair. I think she tried to get up and walk and fell . I called the Nurse Practitioner and she said she'd be right there because there were so many falls on the 3rd floor. Continued interview revealed when asked how the resident was transferred, RN #3 stated, I don't know who did it or how she was transferred, but I had an inkling she had a fracture. Further interview with RN #1 revealed, They are staffed mostly with agency. They are short on techs a lot. I've worked with 3 techs on day shift when we needed 4 or 5. They need more on the dementia (secure) unit because they walk all the time. It's poorly staffed. Interview with the Director of Nursing (DON) on 10/24/17 at 6:50 PM in the conference room when asked what the facility could have done to prevent the second fall for Resident #1 on 8/2/17 the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes with her. Interview with the Administrator with the DON present on 10/24/17 at 6:55 PM in the conference room stated when she began working at the facility in September there were at least 20 agency staff employees working in the facility on a daily basis. Continued interview confirmed the facility currently used 6 different agencies to staff the facility with Nurses and Certified Nurse Aides (CNA's). Further interview with the Administrator confirmed the facility had problems with staffing. Interview with HK #1 on 10/25/17 at 7:55 AM in the 3rd floor dayroom confirmed she found Resident #1 in the doorway of a resident's room on 6/20/17. Continued interview with HK #1, revealed she called for RN #3 and she came out of another resident's room, got a wheelchair, and I picked the resident up by myself under her arms. She was able to stand on her own some, cause the nurse checked her first. Then I sat her down in the wheelchair and the nurse wheeled her back to her room. Continued interview with HK #1 confirmed no other staff members were present or assisted HK #1 or RN #3. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #1 was not capable of using her call light and her Comprehensive Care Plan did not accurately reflect interventions to prevent falls. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview confirmed the facility failed to investigate the cause of the falls for the resident and failed to provide fall interventions to prevent accidents resulting in a fracture to the right hip and a fracture to the left hip of Resident #1. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor of the facility. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #16 was severely cognitively impaired, had no behaviors and required extensive assistance of 2 or more people for bed mobility and transfers, and ambulated in her room only once or twice with assistance of 1 person; was unsteady and only able to stabilize with staff assistance and used a wheelchair for mobility. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Continued review revealed the resident had no previous falls. Further review of a Quarterly MDS dated [DATE] revealed Resident #16 had behaviors of wandering 1-3 days of the previous 7 days, required extensive assistance of 1 person for bed mobility, ambulation in her room, and locomotion on and off the unit and used a wheelchair for mobility. Further review revealed the resident had 1 fall with no injury and 2 falls with injury since the previous assessment. Medical record review of Fall Risk Assessments dated 7/11/17 and 10/10/17 revealed the resident was assessed to be at High Risk for falls. Medical record review of a SBAR Summary dated 7/31/17 at 4:02 PM revealed, .found on floor in door(way) hematoma and bleeding noted on forehead . Medical record review revealed no further documentation regarding the resident's fall or care she received. Medical record review of a hospital record dated 7/31/17 at 5:43 PM revealed .soft tissue swelling of the frontal scalp .Acute subcapital right femoral neck fracture . Continued review of a History and Physical revealed, .She had a laceration to her forehead .The (emergency room ) Physician noticed her right leg was shorter than her left, and a hip xray showed a hip fracture .laceration to forehead with steri strips (porous surgical tape strips which can be used to close small wounds) in place .right leg short and externally rotated . Medical record review of a Medical Progress Note dated 8/2/17 revealed, .Re-admission assessment .seen .following acute hospitalization of fall with head laceration and suspected right hip fracture .no surgical intervention was performed .non-ambulatory and sitting up in (wheelchair) .continues to pick at forehead laceration and has caused increased bleeding .Appearance .Disheveled .large open shallow abrasion to forehead with active bleeding .monitor for falls .Administrative staff to assure appropriate fall prevention interventions are in place and that (patient) is in a safe environment . Continued review revealed the Administrative staff failed to have fall prevention interventions and a safe environment. Medical record review of a SBAR Summary dated 8/24/17 at 7:17 PM revealed, .Resident found on floor in right lateral position (patient) has skin tear on right eyebrow area .Resident usually has wandering on hallway with (wheelchair) sometimes (patient) fall on floor with injury or without injury (patient) need special (wheelchair) for safety .skin tear site dressing done with steri strips . Medical record review of a SBAR Summary dated 9/6/17 at 11:57 AM revealed, .alert with some confusion was called to hallway noticed the resident was sitting on the floor on buttocks noticed blood from forehead clean with (normal saline) and apply bandage . Medical record review of a Medical Progress Note dated 9/11/17 revealed, .seen for (evaluation) and treatment of [REDACTED].indicating (positive) infection .labs obtained following recurrent fall with reopening of forehead abrasion .increased restlessness and anxiousness .Bruising and skin tears to upper extremities .Remains at a high risk of falls. Will hopefully improve with treatment of [REDACTED].Encourage po (by mouth) fluids to prevent further UTI's . Medical record review of an SBAR Sumary dated 9/27/17 at 3:01 PM revealed, .fall no injury . Continued review revealed no further documentation regarding the fall. Medical record review of a Comprehensive Care Plan dated 4/14/16 revealed a focus of .Has had an actual fall with no injury (related to) Unsteady gait, Psychoactive drug use, Poor Balance, Poor communication/comprehension . Continued review revealed the following interventions: (1) 4/14/16 Place frequently used items and call light in reach; Offer/Assist to toilet frequently and as accepted; For no apparent acute injury, determine and address causative factors of the fall; Encourage resident to ask for assistance; Continue interventions on the at-risk plan. (2) 7/25/16 Add anti-roll back to wheelchair. (3) 8/4/17 Bedroom door to be ajar while patient in room alone. Landing strips (fall mats) to both side of bed. (4) Documented on 8/30/17 for 8/24/17. Seating was adjusted with new cushion for wheelchair in place. Observation of Resident #16 on 10/25/17 at 8:30 AM in the 3rd floor dining room revealed she was seated in a wheelchair with a cushion on it at a table waiting for breakfast with 3 other residents. Continued observation revealed she was alert, calm and nonverbal. Continued observation revealed no anti-roll back device to her wheelchair. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to investigate the cause of multiple falls to the resident and place specific, individualized, interventions on the Care Plan to prevent future falls. Continued interview revealed when asked what the 'interventions on the at risk plan' were the DON stated, I have no idea. Further interview confirmed the resident did not have an anti- roll back device to her wheelchair, and the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview with the DON when asked what the facility could have done to prevent multiple falls for Resident #16, the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes. Further interview with the DON confirmed the facility failed to provide appropriate fall interventions to prevent accidents resulting in a forehead hematoma, a right femoral neck fracture, a right eyebrow laceration and multiple bruises to Resident #16. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of the Initial Care Plan dated 9/1/17 did not include safety or fall risk as a focus or potential problem and no interventions to prevent a fall. Medical record review of a Discharge Return/Anticipated Return MDS dated [DATE] revealed the resident was moderately cognitively impaired and had behaviors not directed to others for 1-3 days of the look back period. The resident required supervision for ambulation in his room and had only ambulated in the hallway 1 or 2 times during the look back period. Medical record review of a SBAR Summary dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to the hospital. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline .admitted in May with heart failure exacerbation .started on .midodrine for syncope . Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) pitting edema to flanks . Continued review revealed, .he is chronically hypotensive related to cirrhosis . Medical record review of a Care Plan note dated 9/20/17 revealed, .(Interdisciplinary Team) review of falls .sent out post fall and readmitted .has history of cardiac issues .patient to be out (in) day area as (frequently) as possible . Medical record review of the Comprehensive Care Plan dated 10/17/17 with a focus of Risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs with interventions as follows: (1) Anticipate and meet the resident's needs; (2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; (3) Ensure that the resident is wearing appropriate nonskid footwear when ambulating, transferring, or mobilizing in (wheelchair). Continued review revealed no further interventions to place in the day area frequently to prevent future falls was present. Observation of Resident #17 on 10/25/17 at 8:35 AM in the 3rd floor dining room revealed the resident was seated at a table in a wheelchair with 3 other resident's waiting for breakfast to be served. Continued observation revealed the resident was alert and quiet. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #17 was a high fall risk and had no intervention on Care Plan of increased risk for falls with interventions on the Initial Care Plan dated 9/1/17. Continued interview confirmed the facility failed to identify the resident was at risk for actual falls, and failed to provide an intervention after an actual fall. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview confirmed the facility failed to investigate the cause of the fall and failed to prevent accidents resulting in a fall with a forehead hematoma and hospitalization for Resident #17. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was cognitively intact, required extensive assistance of 1 person for bed mobility, transfers, and ambulation in her room. Continued review revealed she was not steady on her feet and was only able to stabilize with staff assistance. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be High Risk for falls. Medical record review of an initial Comprehensive Care Plan dated 9/26/17 revealed a focus of Safety/Fall Risk related to History of Falls and decreased safety awareness with interventions to observe for placement and function of devices per facility protocols; and Initiate Safety checks as indicated. Medical record review of a Care Conference Note date 9/28/17 revealed, .Resident is a high fall risk . Medical record review of a SBAR Summary dated 10/8/17 at 5:19 AM revealed Resident had a fall and, .resident was getting up from bed to go walk to restroom when she slipped . Medical record review revealed no further documentation regarding the fall was present. Medical record review of a Nurses Note dated 10/15/17 at 9:00 PM revealed, .notified .while assisting patient to the commode, the patient sat down quickly on her own, and bumped her back against the rail next to the commode. At the time the patient stated she hit her head, but (CNA) denies witnessing patient hit her head .will notify the MD (Medical Doctor) if any acute (symptoms) observed or patient expresses pain . Medical record review of a SBAR Summary dated 10/16/17 at 12:13 AM revealed, .fell (complain of) (left) hip pain .resident was transferring self with walker to restroom, staff heard loud noise, enter room observe resident lying on floor on back in front of toilet, stated she hit her head, staff assisted resident up and to bed. (Complain of) pain to (left) hip while walking, notified MD on call orders received to send to hospital for (evaluation) . Medical record review of a Comprehensive Care Plan dated 10/26/17 revealed a focus of at risk for falls related to confusion at times, gait/balance problems, incontinence, and pain with interventions dated 10/26/17 for .(1) 10-8-17 send sock home with family, provide nonskid socks in room; (2) Anticipate and meet the resident's needs. (3) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; (4) Ensure the resident is wearing appropriate nonskid footwear when ambulating, transferring or mobilizing in wheel chair; (5) 10/9/17 landing pads to bedside. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the initial Comprehensive Care Plan for Resident #19 had no interventions to prevent falls and there was no protocol for safety checks. Continued interview confirmed the facility failed to complete the Comprehensive Care Plan with interventions to prevent a fall until after the resident was discharged . Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed Resident #19 was still in the hospital due to the fall on 10/16/17 with a left hip fracture. Continued interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Further interview with the DON confirmed the facility failed to provide fall interventions to prevent accidents resulting in a fracture for Resident #19. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a SBAR Summary dated 10/6/17 revealed, .10/5/17 Resident was found on the floor. Resident was sent to (hospital) as requested by family . Further review revealed the resident was seen in the Emergency Department and sent back to the facility with discharge instructions for a closed head injury and hypertension. Medical record review of an Interdisciplinary (IDT) Post Fall Review dated 10/20/17 revealed Resident #28 fell and was found in her room. Continued review revealed the fall was unwitnessed and no injuries were documented. Further review revealed no documentation of neuro checks. Medical record review of a Comprehensive Care Plan revealed interventions were not initiated until 10/25/17 after the resident sustained [REDACTED]. Interview with the Administrator with the DON present on 10/25/17 at 6:50 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNAs). Continued interview revealed the Administrator stated when she began working at the facility in September there were at least 20 agency staff working in the facility on a daily basis. Interview with DON on 10/31/2017 at 6:10 PM in the conference room confirmed the facility failed to provide interventions to prevent a fall for Resident #28. Refer to F224 K SQC Refer to F309 K SQC

Based on medical record review, review of daily assignment sheets, time punches, agency nurse time sheets, the nursing home licensure checklist, observation and interview, the facility failed to provide sufficient nurse staffing for supervision and care in the prevention of falls to 5 residents (#1, #16, #17, #19, #28) of 7 residents reviewed; failed to provide showers and personal hygiene for 2 residents (#6, #7) of 11 residents reviewed; and failed to monitor behaviors for 2 residents (#20, #22) of 4 residents reviewed. The resulting failure constituted an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident) for failure to provide sufficient nurse staffing for resident care. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor secure unit. Medical record review revealed the resident had a fall on 6/20/17 which resulted in a left [MEDICAL CONDITION] and was hospitalized ; a fall on 8/2/17 which resulted in a right [MEDICAL CONDITION] and was hospitalized . Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor secure unit. Medical record review revealed the resident had a fall on 7/31/17 and sustained a [MEDICAL CONDITION] and right [MEDICAL CONDITION] resulting in hospitalization ; a fall on 8/24/17 resulted in a skin tear to the right eyebrow; a fall on 9/6/17 resulted in bleeding from the forehead; and a fall on 9/27/17 resulted in no injury. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor secure unit. Medical record review revealed the resident had a fall on 9/7/17 and experienced a decreased loss of consciousness, was unresponsive, had head trauma and was hospitalized . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED].#2, History of Falling, Head Injury, Weakness, Hypertension, Anorexia, Lack of Coordination, and Difficulty Walking. Medical record review revealed the resident had a fall on 10/18/17 with unknown injury due to lack of documentation; another fall on 10/15/17 resulting in a bumped back and hit to the head; and a fall on 10/16/17 resulting in a left [MEDICAL CONDITION] and hospitalization . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a fall on 10/5/17, was taken to the emergency room and returned to the facility with a [DIAGNOSES REDACTED]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident received only 1 documented shower on the dates of 9/27/17 through10/23/17 and no further documentation pertaining to showers was provided. Observation of Resident #6 on 10/23/17 at 9:40 AM on the 3rd floor secure unit, revealed the resident presented with strong body odor and was unshaven. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7 on 10/23/17 at 9:40 AM on the 3rd floor secure unit, revealed the resident had dirty nails, clothes, and dried debris on her clothing. Observation of Resident #7 on 10/25/17 at 11:40 AM in the 3rd floor dining room revealed the resident was wearing the same clothing as observed on 10/23/17. Observation of Resident #7 on 10/26/17 at 11:15 AM in the 3rd floor dining room revealed the resident had dried debris on the right side of her mouth and was wearing a soiled top with debris and staining down the front. Interview with Certified Nurse Aide (CNA) #9 on 10/25/17 at 12:05 PM in the 3rd floor revealed the resident had been in the same clothes since 10/23/17. Continued interview confirmed the resident had been wiped off but had not received a shower for several days due to not having enough staff scheduled. Continued interview confirmed the facility failed to carry out and maintain grooming, bathing and personal hygiene for Resident #7. Interview with Resident #23 on 10/24/17 at 10:45 AM in the resident's room revealed the resident wasawake, alert, and oriented, watching television. She stated she frequently had to wait for help and usually had already wet or soiled herself before the Certified Nurse Aides (CNAs) can get around to performing every 2 hour rounds for turning and drying/cleaning her. Continued interview revealed it embarrassed her to wet or soil herself. Further interview revealed she had waited for longer amounts of time in the evenings, nights, and on the weekends, waiting for up to 40 minutes before being helped on most evenings, nights, and weekends. Interviews with Residents #24, #25, and #26 on 10/24/17 at 10:55 AM in the 2nd floor south hall revealed they have had to wait for help, after pushing their call lights especially on the weekend nights. Futher interview confirmed they stated the wait time was 20 to 30 minutes. Interview with Resident #27 on 10/24/17 at 11:10 AM in her room revealed many times the CNAs did not turn her every 2 hours, it would be longer than every 2 hours. Continued interview revealed many times she had wet or messed herself which made her feel bad. Further interview revealed she had to ask for water to fill her water pitcher when the previous shift forgot to fill the pitcher. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and 9/14/17 and was discharged to a psychiatric facility on 10/9/17 with [DIAGNOSES REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's behaviors in the SBAR Summaries, Progress Notes, Nurses Notes dated 9/25/17 to 10/26/17 revealed agitation, removal of several window blinds from the windows and carried the blinds down the hall, throwing an empty bucket, yelling, and grabbing at the nursing staff hard enough to leave bruising. Medical record review of the Psychiatric Diagnostic Evaluations performed by the Psychiatric Nurse Practitioner dated from 9/11/17 to 10/24/17 revealed behaviors of impulsive, anxious, confused, wandering, trying to shoot others playfully with a plastic plant water bottle, verbal and physical aggression against other residents and staff members and threatening toward staff especially when they try to redirect. Interview with the Staffing Coordinator on 10/24/17 at 8:50 AM in the conference room revealed CNA #6 (agency staff) was listed on the daily schedule; however, was not in the facility for direct resident care from 9:30 AM to 3:30 PM on Monday, Wednesday, and Friday when he accompanied and remained with a resident on the 3rd floor to his [MEDICAL TREATMENT] appointment. Continued interview confirmed there was no CNA to fill-in for CNA #6 while he was not on the floor. Telephone interview with Registered Nurse (RN) #3 on 10/24/17 at 3:50 PM revealed a lot of resident falls occur on all shifts and stated the facility is short-staffed; not having enough CNAs and the facility was staffed mostly with agency staff and they seldom arrived on time. Continued interview revealed she had worked with only 3 CNAs on day shift when 4 to 5 CNAs were needed. Interview with RN #1 (agency nurse) on 10/24/17 at 4:40 PM at the 2nd floor medication cart revealed she is scheduled for shifts on the 2nd and 3rd floors of the facility and stated it was mostly staffed by agency nurses and CNAs. Continued interview revealed the schedule is short on CNAs a lot and she had worked with 3 CNAs on the day shift when 4 or 5 more staff is needed. Further interview revealed more staff is needed on the 3rd floor secure unit because most of the residents walk all the time and stated, .It's poorly staffed . Interview with Licensed Practical Nurse (LPN) #1 on 10/24/17 at 5:40 PM on the 3rd floor secure unit revealed an additional CNA would help to observe dementia residents on the 3rd floor, especially the secure unit side. Continued interview revealed he stated, .the residents wander about and another CNA would really help in redirection of the more impaired and dependent residents . Interview with CNA #4 on 10/24/17 at 6:38 PM on the 3rd floor secure unit revealed only 3 CNAs are usually scheduled for the entire 3rd floor and 3 CNAs are not enough for secure unit residents with Sundow[DIAGNOSES REDACTED], Dementia, Confusion, and Wandering. Continued interview revealed the south hall of the 3rd floor had 7 residents totally bedridden, needed assistance with meals and had to wait for assistance with meals. Interview with the Director of Nursing (DON) on 10/24/17 at 6:50 PM in the conference room revealed when asked what the facility could have done to prevent the falls on the 3rd floor, the lack of showers and personal hygiene, the lack of adequate hydration, and the behavior monitoring she stated, .If we had our own staff it would have been easier for consistency and to notice any subtle changes . Interview with CNA #2 on 10/25/17 at 9:25 AM on the 3rd floor, south hall revealed the residents received more attention from the CNAs when 4 to 5 were scheduled on days and evenings. Continued interview revealed at least 3 CNAs scheduled for the secured unit helped to monitor residents that wander about, have confusion, and require redirection. Further interview revealed the CNA agreed with statements made by Resident #23 and Resident #27 about getting help from CNAs on time and stated the 2 residents are credible. Continued interview confirmed when 3 to 4 CNAs are scheduled she is unable to make resident rounds, many times finding the bedbound residents with wet or soiled adult briefs and linens. Interview with CNA #1 on 10/25/17 at 9:30 AM on the 3rd floor, south hall revealed if 3 to 4 CNAs were scheduled for the entire 3rd floor, it was hard to make the every 2 hour checks on the residents. Interview with CNA #5 on 10/25/17 at 10:00 AM on the 2nd floor nurses station revealed working on the 3rd floor was difficult with just 3 CNAs. Continued interview revealed at least 2 CNAs were needed for the secure unit, leaving 1 CNA for the south hall. Further interview confirmed Resident #23 and Resident #27 were correct on their statements about getting help timely. Continued interview confirmed residents requiring 2 staff and every 2 hour turning were not getting turned and changed timely. Interview with the Administrator and the DON present on 10/25/17 at 6:50 PM, in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and CNAs. Continued interview revealed the Administrator stated when she began working at the facility in September there were at least 20 agency staff working in the facility on a daily basis. Telephone interview with the Medical Director on 10/30/17 at 2:25 PM revealed the number of falls on the secured unit, .may be a little higher than most and maybe it does has to do with staffing. Review of the daily assignment sheets, time punches, agency nurse time sheets, and nursing home licensure checklist revealed the range of census for the 3rd floor (a long hall with a nurses station and dining room in the middle with a keypad used to enter the dining room) for the period of mid-September 2017 to October 2017 was 45 to 47 residents with the secure unit (half of the long hall, also called north hall) ranging from 23 to 29 residents. Continued review of the daily assignment sheets, time punches, and agency nurse time sheets for dates coinciding with complaints and accidents dated 9/3/17, 9/20/17, 9/24/17, 9/27/17, 10/4/17, and 10/15/17 revealed the nursing schedule with the following data: 9/3/17: 45% agency nurses and 45% agency CNAs for the entire facility. 60% agency nurses and 45% agency CNAs for the 3rd floor. 2 nurses worked double shifts; 3 CNAs worked double shifts. 9/20/17: 0% agency nurses and 36% agency CNAs for the entire facility. 0% agency nurses and 9% CNAs for the 3rd floor. 2 nurses worked double shifts; 3 CNAs worked double shifts. 9/24/17: 36% agency nurses and 14% agency CNAs for the entire facility. 20% agency nurses and 9% agency CNAs for the 3rd floor. 2 nurses worked double shifts; 2 CNAs worked double shifts. 9/27/17: 36% agency nurses and 30% agency CNAs for the entire facility. 20% agency nurses and 36% agency CNAs for the 3rd floor. 1 nurse worked double shifts; 3 CNAs worked double shifts. 10/4/17: 27% agency nurses and 28% agency CNAs for the entire facility. 20% agency nurses and 8% agency CNAs for the 3rd floor. 2 nurses worked double shifts; 3 CNAs worked double shifts 10/15/17: 63% agency nurses and 92% agency CNAs for the entire facility. 40% agency nurses and 42% agency CNAs for the 3rd floor. 3 nurses worked double shifts; 6 CNAs worked double shifts Interview with the DON and the Director of Operations on 10/30/17 at 4:50 PM in the conference room confirmed the facility failed to provide sufficient nursing staff to provide quality of care, supervision and intervention to the residents. Refer F224 K Refer F309 K Refer F323 K

Based on the facility policy review, medical record review, observation, and interview, the facility failed to prevent and protect 2 residents (#2, #16) from abuse of 23 residents reviewed. This failure resulted in harm to Residents #2 and #16. The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised date ,[DATE], .each resident has the right to be free from abuse .the facility Administrator is the Abuse Prevention Coordinator . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record reveiw of an quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively intact with no moods but delusional behaviors exhibited. Further medical record review of the quarterly MDS revealed the resident is independent with set-up for Activities of Daily Living (ADL's). Medical record review of an Incident/Accident Report dated [DATE] revealed Resident #2 was assualted twice by Resident #22. Continued review revealed .Patient was yelling this nurse went into her room. She states (Resident #2) that he (Resident #22) was trying to kill her, she states that he grabbed her left arm, and she has a bruise on her left arm . Medical record review of a Nurses Note of the Resident dated [DATE] 11:17 AM revealed .Resident stay(ed) at (in) dining room pt (patient) stated that 'still I have anxiety' r/t (related to) release fire extinguisher pt has bruises on arm . Medical record review of the Nurses Note dated [DATE] 9:10 AM revealed Licensed Practical Nurse #2 .pt(Patient) reported that she was hit on her left upper arm and left forearm, side of face. Bruising noted to left arm and slight swelling to left side of face. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review of an admission MDS dated [DATE] revealed the resident was moderately cognitively intact and extensive assistance with help of 1 staff person for all ADL's except bathing requiring total assistance of 1 staff person. Further medical record review of admission MDS dated [DATE] revealed moderately cognitively intact and extensive assistance with help of 1 staff person for all ADL's except bathing requiring total assistance of 1 staff person. Medical record review of a note dated [DATE] at 3:38 AM Situation, Background, Assessment, Recommendation, (SBAR) Summary revealed .Resident is agitated, for no apparent reason. He has an long object in his hand, swinging it at staff and one of the residents. He grabbed a fire extinguisher off of the wall and began to spray it at me and a CNT (Certified Nursing Technician). We were unable to get the extinguisher from him. MD (Medical Doctor) was notified and gave order to send resident out (to the hospital) for further evaluation . Observation and interview of Resident #2 on [DATE] at 9:00 AM in the 3rd floor dining room revealed the resident stated .I almost died last night, the man behind the wooden part tried to kill me, he hit me here, and grabbed my arm, I think he is from another town . Resident #2 had visible bruising on left forearm and on outer forearm. Resident touched the left side of her face showing, .he hit me here and it hurts in here (showing the inside of her mouth) . Interview with Registered Nurse (RN) #5 on [DATE] at 3:00 PM in the conference room revealed Resident #2 was grabbed and hit by Resident #22 around 1:15 AM in Resident #2's room. Continued interview revealed she was informed of the incident verbally by Licensed Practical Nurse (LPN) #3 in morning report. Further interview confirmed RN #5 did not report the incident to the Abuse Coordinator (Administrator). Interview with Director of Nursing (DON) on [DATE] at 1:50 PM in the conference room confirmed that she was made aware of the incident between Resident #2 and Resident #22. DON stated .I was here around 2:00 AM, and helped evacuate all the residents on the secured unit while we cleaned the hall and rooms; all beds had to be changed from the powder in the fire extinguishers. Further interview confirmed the DON failed to start an investigation of abuse. Continued interview with the DON confirmed the facility failed to prevent, protect, investigate and report physical abuse of Resident #2. Medical record review, observation, and interview, revealed the facility failed to protect Resident #2 from abuse by Resident #22. Further investigation revealed the facility failed to report previous abuse, on [DATE], of Resident #2 by Resident #22. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, exhibited behaviors of wandering ,[DATE] days of the previous 7 days, and used a wheelchair for mobility. Medical record review of a SBAR Summary dated [DATE] at 8:07 PM revealed, .Resident (#16) has a habit (holding others {wheelchair} or clothes) (patient) grasp fistful of (Resident #20's clothing) so (Resident #20) upset and smacking her face . Medical record review of a SBAR Summary dated [DATE] at 8:53 PM revealed, .Resident up in (wheelchair) and wandering .observed face skin redness almost disappeared . Interview with the DON on [DATE] at 9:20 AM in the conference room confirmed she was not aware of a resident to resident altercation on [DATE] between Resident #16 and Resident #20. Telephone interview with RN #2 on [DATE] at 10:20 AM confirmed she was caring for Resident #16 on [DATE] on the 3:00 PM-11:00 PM shift and was at the nurse's station on the 3rd floor when someone told her Resident #20 hit Resident #16. Continued interview revealed RN #2 was unable to remember who reported the incident to her. Continued interview confirmed RN #2 separated the 2 residents and noted Resident #16 had a red line on the left side of her face below the eye, which was present for at least 2 days, and confirmed she wrote the SBAR Summary. Continued interview with RN #2 when asked if she had been trained on abuse prevention stated, Oh sure. I've had several in-services, the last one was less than a month. Continued interview revealed when asked if she thought it was abuse, RN #2 stated, No. I didn't see it as abuse. It's a secure unit with combative patients. This wasn't the first time (Resident #20) was combative. I've seen this many times. The Nurse Practitioner gave orders for meds (medicines) or sent them to the hospital so it's behaviors. Continued interview with RN #2 when asked if she reported the resident to resident altercation to the Abuse Coordinator stated, We report to the Unit Manager and she reports to the DON. I document on the SBAR Summary so they know. No. I did not notify the Administrator . Interview with the DON on [DATE] at 6:40 PM in the conference room confirmed the facility failed to prevent and protect Resident #16 from abuse. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and [DATE], and was discharged to a psychiatric facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Return Anticipated MDS dated [DATE] revealed the resident was severely cognitively impaired and had behaviors of inattention, physical behaviors directed to others, and wandering. Continued review revealed she received antipsychotic, antianxiety, and antidepressant medications. Medical record review of a SBAR Summary dated [DATE] revealed, .increased confusion and combative disorder observed .wandering everywhere, (patient) opened break room, linen room .stated that 'I have to get out of here. I will go home. If somebody touch(es) me I will kill them' .kicking with agitation .transfer to hospital . Medical record review of a SBAR Summary dated [DATE] revealed, .Resident returned from hospital on [DATE] as (with) same problems .lunch time she opened door and suddenly throw (threw) the food toward staff .when staff trying to control her behavior she hit, scratched staff and yelling out. After closed door she throw (threw) the food tray on the floor . Medical record review of a Behavior Note dated [DATE] revealed, .increasing agitation this pm. combative .(continues) back and forth between room & nurses station . Medical record review of Behavior Note dated [DATE] revealed, .wandering hallway sometimes .entering other resident's room, (patient) has agitation. At 6 PM .in room [ROOM NUMBER] and stood up from (wheelchair) (knocking on) window and stated 'I have to get out of here' . Medical record review of a SBAR Summary dated [DATE] revealed, .Resident has been having psychiatric behavior recently pt (patient) increased agitation, self harming and others harming behavior, wandering, kicking toward staff, verbally aggressive, restlessness noted . Medical record review of a Behavior Note dated [DATE] revealed, .Resident returned from hospital still pt has confusion, wandering, agitation observed pt trying to use elevator for (to) get out of here and lay (laid) down in front of elevator . Medical record review of a SBAR Summary dated [DATE] revealed, .Resident has been having agitation, combative disorder, suicidal idea so multiple times pt transferred to psychiatric hospital. Today pt has significant behavior observed pt trying to jumping (jump) toward window for suicide and keeping razor to her abdomen also pt crying all day long . Medical record review of a Nurses Note dated [DATE] revealed, .Pt rolling around day room in (wheelchair) rolling up to pt, striking at another pt. Pt rolling around reaching and try to hit at other residents. Interview with the DON on [DATE] at 6:40 PM in the conference room confirmed the facility failed to prevent the behaviors of Resident #20 from escalating to causing harm to Resident #2 and #16.

Based on facility policy review, medical record review and interview, the facility failed to notify the Physician or Nurse Practitioner of a [MEDICAL CONDITION] for 1 resident (#1) of 7 residents reviewed. This failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for the resident. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Review of facility policy, Changes in Resident Condition, revised 2/2017 revealed, .Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture. (Patient) was recently hospitalized for [REDACTED].according to staff thought she could walk .got up without assistance and fell . No further details of events surrounding were known by the (Nurse Practitioner) at this time .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .Radiography .Testing Reviewed: Date 8/03/17 Test Results: Left femoral neck fracture .Administration to (evaluate) and investigate falls for any possible cause of recurrent falls and for future fall precautions interventions .(positive) pain during transfer to stretcher . Interview with the NP #1 on 10/24/17 at 2:20 PM in the conference room confirmed she was notified of the fall for Resident #1 on 8/2/17 verbally by staff. Continued interview confirmed she ordered an X-ray on 8/2/17. Further interview confirmed she was not notified on 8/2/17 the X-ray results revealed a fracture to Resident #1's left hip. Continued interview confirmed the Nurse Practitioner learned of the fracture for Resident #1 on 8/3/17 when she began rounding between 6:30 AM and 7:00 AM and found the results herself. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to report X-ray results of a fracture to the Physician or Nurse Practitioner for Resident #1 on 8/2/17 at 5:01 PM which caused a delay in treatment to Resident #1 until she was transferred to the hospital on [DATE] at 8:30 AM resulting in Immediate Jeopardy. Refer to F 224 K SQC Refer to F-309 K SQC Refer to F-323 K SQC Refer to F-353 K SQC Refer to F-490 K Refer to F-501 K Refer to F-520 K

Based on policy review, medical record review, review of accident reports, observations and interview, it was determined the facility failed to ensure interventions were in place to prevent falls and injury to 1 of 3 (Resident #150) sampled residents of the 4 residents with falls. The failure to implement care plan interventions resulted in actual harm when Resident #150 sustained a fractured nose that required surgery and lacerations that required stitches. The facility failed to ensure the environment was safe as evidenced by unsecured razors in 1 of 82 (room 301) rooms. The findings included: 1. Review of the facility's "Fall Management" policy documented, "...New admissions will be placed on the Falling Star Program... If determined by the IDT (interdisciplinary team) that the resident is at risk, the Falling Star will be continued and interventions in the Plan of Care will be updated... If resident is identified for the program, a falling star symbol will be placed on any or all of the locations below: Over the bed... On assuasive devices... wheelchair... Placement of the symbol(s) will be determined by each individual facility... Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks... The care plan will be reviewed/revised as indicated... The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. Visual reminders will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall..." Medical record review for Resident #150 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim care plan dated 3/13/14 documented, "...Problem/Need... Falls: Actual (checked) History of Falls (checked) Decreased safety awareness (checked).. .Interventions Initiated... Falling Star Program (checked) Orient resident to room/environment (checked) Place call light within reach (checked) Initiate safety checks as indicated (checked)..." Review of the falls care plan dated 3/21/14 documented, "...At risk for Falls... Approach... Falling Star Program (checked)... Other mats to floor (checked)... Offer/Assist to toilet frequently and as accepted... 3/22/14 dyson to chair (checked)..." Review of the care plan dated 5/8/14 documented, "...Problem/Need... History of falls (checked)... Interventions Initiated... Falling Star Program (checked)... Observe frequently during increased wandering to ensure safety..." Review of accident reports documented the following" a. 4/10/14 - "...Resident was found on the floor in a sitting position scooting across the floor in his room by the bathroom door... RECOMMENDATIONS / NEW INTERVENTIONS... Scoop Mattress..." b. 4/12/14 - "...Incident/Injury Type... Lt (left) eyebrow... Nose Laceration... Pt (patient) fell in hallway hit face... SUMMARY OF INVESTIGATION... Walk out into hall fell face forward toward floor..." Review of a nurse's note documented the following: a. 4/12/14 - "...Returned from (named facility)... Facial bruising noted fracture nose per report from (named facility)..." b. 4/16/14 - "...Risk Mtg. (meeting) Pt (patient) fell on [DATE]. Pt found on floor in bedroom. Scoop mattress added to bed. Pt. fell again on 4/12/14. Walked into hallway and fell . Pt. hit face on floor. Sent to ER (emergency room ) Stitches received..." c. 5/7/14 - "...pt. (patient)... going to (named facility) for surgery of broken nose..." Observations in Resident #150's room on 9/2/14 at 3:01 PM, on 9/3/14 at 8:23 AM and on 9/4/14 at 7:59 AM and 11:40 AM, revealed there was no scoop mattress on the bed nor were there any mats beside the bed. Observations at the 3rd floor nurses' station on 9/3/14 at 8:23 AM, revealed Resident #150 seated in a wheelchair with no dyson in the chair. Observations in the day room on 9/4/14 at 7:59 AM, 11:40 AM and at 3:40 PM, revealed Resident #150 seated in a wheelchair with no dyson in the chair. During an interview in the day room on 9/4/14 at 3:40 PM, Nurse #2, the unit manager, confirmed the dyson was not present in the wheelchair. During an interview in the Director of Nursing's (DON) office on 9/4/14 at 2:40 PM, the DON was asked about Resident #150's fractured nose. The DON stated, "He might have had a fall. I don't remember him having a fall at that time (5/8/14). If I remember his nose wasn't lined up right. We did a follow up on him. He had an appointment with somebody just to see him." The DON was then asked if Resident #150 broke his nose on the fall that occurred on 4/12/14. The DON stated, "I don't think we determined that, but it wasn't lined up after the fall." During an interview in the DON's office on 9/4/14 at 3:00 PM, Nurse #3, a Unit Manager, was asked to review the falls and interventions for clarity for this surveyor. Nurse #3 stated, "On 4/12/14, he went for for stitches. They told us that day that his nose was broken but they did not do anything then." Nurse #3 stated, "There are 2 places the immediate interventions would be, on the post fall review or the risk meeting notes. Let's look at the care plan... on fall on 3/13/14. I think on 3/15/14 the intervention was bed alarm. No, I think on 3/13/14 bed alarm and 3/15/14 chair alarm. On 3/23/14 a dyson under the wheelchair cushion." At this time minimum data set (MDS) Coordinator #1 came in and looked at the care plan for interventions and dates. MDS Coordinator #1 stated, "On 3/15/14 we have landing pads but it is not dated." During an interview in the elevator on 9/4/14 at 4:25 PM, MDS Coordinator #1 was asked if the fall mats are on the floor all the time even if the resident is not in bed. MDS Coordinator #1 stated, "All the time unless they are being cleaned then they are up against the wall." During an interview in the 300 hall outside Resident #150's room on 9/4/14 at 2:20 PM, Nurse #4 was asked what is in place for Resident #150 if he is high risk for falls. Nurse #4 stated, "He should be on the falling star program." Nurse #4 looked at the resident's door and said he should have a star on there (pointing to the wall beside his room). Nurse #4 then went down the hall to another room and removed a star from the door and brought it to Resident #150's door and placed that star on the door. Nurse #4 stated, he doesn't have one but he does have one now." The star on the door was labeled for the B bed, (Resident #150 was in the A bed). Nurse #4 was then asked what safety checks are. Nurse #4 stated, "We check every 2 hours, like if they have a fall and we get neuro checks." During an interview in Resident #150's room on 9/4/14 at 3:45 PM, certified nursing assistant (CNA) #4 was asked if there had ever been mats beside Resident #150's bed. CNA #4 stated, "No." then, CNA #4 confirmed there were no mats on the floor for Resident #150. During an interview at the nurses station on 9/4/14 at 3:50 PM, Nurse #4 was asked if Resident #150 had ever had fall mats. Nurse #4 stated, "I'm not sure. I don't think so. No he does not." During an interview in Resident #150's room on 9/4/14 at 4:25 PM, MDS Coordinator #1 confirmed the landing mats were not in the room. During an interview in the Administrator's office on 9/4/14 at 4:50 PM, MDS Coordinator #1 was asked about toileting for Resident #150. MDS Coordinator #1 stated, "I can't find anything (documented related to cueing the resident to toilet every 2 hours)." During an interview in the 3rd floor day room on 9/4/14 at 5:40 PM, Nurse #2, a Unit Manager, was asked about the the mats and the dyson for Resident #150. Nurse #2 stated, "I put the scoop mattress on myself and the landing mats when he was on the first floor. I don't know if I documented it or not. If I did it is in my nurses notes." Nurse #2 was then asked if Resident #150 had a dyson cushion. Nurse #2 stated, "A few weeks ago the Rehab (Rehabilitation) Director was new and came in and told us to get the Dyson off everything because of shearing problems." During an interview in the conference room on 9/5/14 at 10:15 AM, the DON was asked where the fall would be documented when Resident #150 fell , received a laceration requiring stitches and a broken nose. The DON stated, "I'm not sure." The DON did not provide any additional documentation and there was no documentation in the nurses' notes of the fall. The failure to implement care plan interventions resulted in actual harm when Resident #150 sustained a fractured nose that required surgery and lacerations that required stitches. 2. Observations in the bathroom of room 301 on 9/2/14 at 2:45 PM, on 9/3/14 at 9:21 AM and 3:05 PM, on 9/4/14 at 8:42 AM, 2:30 PM and 6:15 PM and on 9/5/14 at 8:30 AM revealed a unsecured razor. During an interview in Resident #150's room on 9/3/14 at 4:17 PM, Nurse #2 was asked if razors should be stored in a resident's bathroom. Nurse #2 stated, "(Resident #150) is able to sit in wheelchair, not able to get into the bathroom by herself, unable to reach for items. The family has requested they (razors) be kept there." Nurse #2 was asked about other resident's getting razors. Nurse #2 stated, "We don't have residents wandering on this hall..." During an interview in the conference room on 9/5/14 at 10:04 AM, the DON was asked if razors should be stored unsecured. The DON stated, "I wouldn't recommend it."

Based on policy review, medical record review, review of accident reports, observation and interview, it was determined the facility failed to ensure care plan interventions were in place and implemented to prevent falls and injury to 1 of 3 (Resident #150) sampled residents of the 4 residents with falls. The failure to implement care plan interventions resulted in actual harm when Resident #150 sustained a fractured nose that required surgery and lacerations requiring stitches. The findings included: Review of the facility's "Fall Management" policy documented, "...New admissions will be placed on the Falling Star Program... If determined by the IDT (interdisciplinary team) that the resident is at risk, the Falling Star will be continued and interventions in the Plan of Care will be updated... If resident is identified for the program, a falling star symbol will be placed on any or all of the locations below: Over the bed... On assuasive devices... wheelchair... Placement of the symbol(s) will be determined by each individual facility... Each facility is responsible for implementing individualized interventions related to/for each resident's fall risks... The care plan will be reviewed/revised as indicated... The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. Visual reminders will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall..." Medical record review for Resident #150 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim care plan dated 3/13/14 documented, "...Problem/Need... Falls: Actual (checked) History of Falls (checked) Decreased safety awareness (checked).. .Interventions Initiated... Falling Star Program (checked) Orient resident to room/environment (checked) Place call light within reach (checked) Initiate safety checks as indicated (checked)..." Review of the falls care plan dated 3/21/14 documented, "...At risk for Falls... Approach... Falling Star Program (checked)... Other mats to floor (checked)... Offer/Assist to toilet frequently and as accepted... 3/22/14 dyson to chair (checked)..." Review of the care plan dated 5/8/14 documented, "...Problem/Need... History of falls (checked)... Interventions Initiated... Falling Star Program (checked)... Observe frequently during increased wandering to ensure safety..." Review of accident reports documented the following" a. 4/10/14 - "...Resident was found on the floor in a sitting position scooting across the floor in his room by the bathroom door... RECOMMENDATIONS / NEW INTERVENTIONS... Scoop Mattress..." b. 4/12/14 - "...Incident/Injury Type... Lt (left) eyebrow... Nose Laceration... Pt (patient) fell in hallway hit face... SUMMARY OF INVESTIGATION... Walk out into hall fell face forward toward floor..." Review of a nurse's note documented the following: a. 4/12/14 - "...Returned from (named facility)... Facial bruising noted fracture nose per report from (named facility)..." b. 4/16/14 - "...Risk Mtg. (meeting) Pt (patient) fell on [DATE]. Pt found on floor in bedroom. Scoop mattress added to bed. Pt. fell again on 4/12/14. Walked into hallway and fell . Pt. hit face on floor. Sent to ER (emergency room ) Stitches received..." c. 5/7/14 - "...pt. (patient)... going to (named facility) for surgery of broken nose..." Observations in Resident #150's room on 9/2/14 at 3:01 PM, on 9/3/14 at 8:23 AM and on 9/4/14 at 7:59 AM and 11:40 AM, revealed there was no scoop mattress on the bed nor were there any mats beside the bed. Observations at the 3rd floor nurses' station on 9/3/14 at 8:23 AM, revealed Resident #150 seated in a wheelchair with no dyson in the chair. Observations in the day room on 9/4/14 at 7:59 AM, 11:40 AM and at 3:40 PM, revealed Resident #150 seated in a wheelchair with no dyson in the chair. During an interview in the day room on 9/4/14 at 3:40 PM, Nurse #2, the unit manager, confirmed the dyson was not present in the wheelchair. During an interview in the Director of Nursing's (DON) office on 9/4/14 at 2:40 PM, the DON was asked about Resident #150's fractured nose. The DON stated, "He might have had a fall. I don't remember him having a fall at that time (5/8/14). If I remember his nose wasn't lined up right. We did a follow up on him. He had an appointment with somebody just to see him." The DON was then asked if Resident #150 broke his nose on the fall that occurred on 4/12/14. The DON stated, "I don't think we determined that, but it wasn't lined up after the fall." During an interview in the DON's office on 9/4/14 at 3:00 PM, Nurse #3, a Unit Manager, was asked to review the falls and interventions for clarity for this surveyor. Nurse #3 stated, "On 4/12/14, he went for for stitches. They told us that day that his nose was broken but they did not do anything then." Nurse #3 stated, "There are 2 places the immediate interventions would be, on the post fall review or the risk meeting notes. Let's look at the care plan... on fall on 3/13/14. I think on 3/15/14 the intervention was bed alarm. No, I think on 3/13/14 bed alarm and 3/15/14 chair alarm. On 3/23/14 a dyson under the wheelchair cushion." At this time minimum data set (MDS) Coordinator #1 came in and looked at the care plan for interventions and dates. MDS Coordinator #1 stated, "On 3/15/14 we have landing pads but it is not dated." During an interview in the elevator on 9/4/14 at 4:25 PM, MDS Coordinator #1 was asked if the fall mats are on the floor all the time even if the resident is not in bed. MDS Coordinator #1 stated, "All the time unless they are being cleaned then they are up against the wall." During an interview in the 300 hall outside Resident #150's room on 9/4/14 at 2:20 PM, Nurse #4 was asked what is in place for Resident #150 if he is high risk for falls. Nurse #4 stated, "He should be on the falling star program." Nurse #4 looked at the resident's door and said he should have a star on there (pointing to the wall beside his room). Nurse #4 then went down the hall to another room and removed a star from the door and brought it to Resident #150's door and placed that star on the door. Nurse #4 stated, he doesn't have one but he does have one now." The star on the door was labeled for the B bed, (Resident #150 was in the A bed). Nurse #4 was then asked what safety checks are. Nurse #4 stated, "We check every 2 hours, like if they have a fall and we get neuro checks." During an interview in Resident #150's room on 9/4/14 at 3:45 PM, certified nursing assistant (CNA) #4 was asked if there had ever been mats beside Resident #150's bed. CNA #4 stated, "No." then, CNA #4 confirmed there were no mats on the floor for Resident #150. During an interview at the nurses station on 9/4/14 at 3:50 PM, Nurse #4 was asked if Resident #150 had ever had fall mats. Nurse #4 stated, "I'm not sure. I don't think so. No he does not." During an interview in Resident #150's room on 9/4/14 at 4:25 PM, MDS Coordinator #1 confirmed the landing mats were not in the room. During an interview in the Administrator's office on 9/4/14 at 4:50 PM, MDS Coordinator #1 was asked about toileting for Resident #150. MDS Coordinator #1 stated, "I can't find anything (documented related to cueing the resident to toilet every 2 hours)." During an interview in the 3rd floor day room on 9/4/14 at 5:40 PM, Nurse #2, a Unit Manager, was asked about the the mats and the dyson for Resident #150. Nurse #2 stated, "I put the scoop mattress on myself and the landing mats when he was on the first floor. I don't know if I documented it or not. If I did it is in my nurses notes." Nurse #2 was then asked if Resident #150 had a dyson cushion. Nurse #2 stated, "A few weeks ago the Rehab (Rehabilitation) Director was new and came in and told us to get the Dyson off everything because of shearing problems." During an interview in the conference room on 9/5/14 at 10:15 AM, the DON was asked where the fall would be documented when Resident #150 fell , received a laceration requiring stitches and a broken nose. The DON stated, "I'm not sure." The DON did not provide any additional documentation and there was no documentation in the nurses' notes of the fall. The failure to implement care plan interventions resulted in actual harm when Resident #150 sustained a fractured nose that required surgery and lacerations that required stitches.