Every finding on record at Green Meadows Health & Rehabilitation

Based on observation, interview, and policy review, the facility failed to provide food storage in a safe and consistent manner. Specifically, food items were observed open and unlabeled/ undated as to when the package/bottle/bags/boxes was opened. This had the potential to affect 78 of 79 residents who consumed food from the kitchen. The findings include: Review of undated policy provided by the facility titled, Guidelines for Storage subtitle Date Your Products with Use by Dates revealed use-by date for flour and syrup was one year, and two years for vinegar. The policy further revealed the use by date for frozen potatoes was eight months. During an observation and initial kitchen walk through with the Dietary Manager (DM) on 10/22/2024 beginning at 9:48 AM, the following was observed: 1. In the general kitchen area - four bags of flour were in an uncovered bin. The bags of flour were unsealed and unlabeled with the open date and expiration dates. At the time of this observation, the DM stated she was waiting on a replacement lid for the flour bin. The DM also stated she was unsure of how long the flour was good for before it had to be discarded. 2. In the general kitchen area there was an open, unlabeled bottle of Reliance brand pancake and waffle syrup. At the time of the observation, the DM stated the bottle did not belong to the kitchen and had been left there by another department. DM acknowledged the bottle was the responsibility of the kitchen staff. 3. In the dry product storage room, there were three open, unlabeled one-gallon bottles of white vinegar. At the time of the observation, the DM stated the vinegar was not used for patient food, but to clean the steamer. The DM acknowledged that since the vinegar was stored in the in the resident food area, it could be used in resident's food. 4. In the dry food storage area, there was a toolkit box containing cake decorating items and flavors. All items in the kit were undated and unlabeled. At the time of the observation, the DM stated she had no idea what the box was and what it was doing in the resident food storage area. 5. In the walk-in freezer, there was one open, unlabeled bag of cookie dough; two open, unlabeled bags of garlic bread; and one open bag of unlabeled hash browns. At the time of the observation, the DM acknowledged the food items should have been labeled with the open dates and should have been stored in their original boxes. During an interview with the Administrator on 10/25/2024 at 3:15 PM, she stated it was her expectation that all open food items should be labeled with the date opened and with an expiration date.

Based on observations, interviews and document review, the facility failed to ensure the call light systems annunciator was operating at two of two nurses' stations (Transition and Orchard). This deficient practice could result in residents being unable to obtain assistance with their activities of daily living. The findings include: During an observation on 10/22/2024 at 4:59 PM at the Transition nurse's station, the call light system did not alarm at the nurses' station. Interview at that time with Licensed Practical Nurse (LPN) 1 and the Assistant Director of Nursing (ADON) revealed the annunciation system had been damaged during a storm, which had occurred in the spring. Both stated the lights above the doors still worked so staff could watch when a resident put on their call light requesting assistance. During an observation on 10/23/2024 at 4:00 PM at the Orchard nurse's station, the call light system did not alarm at the nurses' station when activated. Observation on the Oak hallway of the Transition unit on 10/22/2024 at 5:30 PM revealed a light was on above R59's door indicating the resident's call light had been activated, R59's call light appeared outside of her room; however, did not ring or light the annunciation system at the nurses station. During an interview on 10/23/2024 at 4:12 PM with Certified Nursing Assistants(CNA)1, CNA3, and LPN5, they revealed the residents alert staff when they required assistance by activating their call lights. The light above the door would light up but did not ring at the nurses' stations. Usually someone is down the hall watching and could respond to the light. The residents who were able to understand had been given small hand bells to use to also alert staff if they required assistance. During an interview on 10/25/2024 at 9:53 AM, CNA2 and Certified Medication Technician (CMT) 1 stated that they have been doing 30-minute rounds on each hall to ensure the residents needs had been met. Both stated the residents who had a hand bell were able to understand how to use it. Review of the facility's Call Light Audits from October 2023 through September 2024 revealed the audits were conducted by various department supervisors. One resident room was observed per day. There were no documented times for what time of the day the audit had been completed. During an interview on 10/25/2024 at 2:42 PM, the Director of Nursing (DON) confirmed the Call Light Audits were only being conducted one day a week in one room each day. The DON stated that the Call Light Audits did not cover all different times of the day and the weekends. During an interview on 10/25/2024 at 2:50 PM, the Administrator revealed the call light annunciators had been damaged by a storm in July 2024. Per the Administrator, the current owner was aware of the damage but had not fixed the call light system. The Administrator stated the facility did not have a policy regarding call lights.

Based on observations and interviews, the facility failed to ensure two of two (Transition and Orchard) living room couches used by residents were maintained in a safe manner. The unrepaired couches could be a fall risk and possible risk for physical injury. This deficient practice has the potential to affect all 79 residents and their visitors in the facility. The findings include: During an observation on 10/23/2024 at 12:30 PM the Transition wing living room had a half-circle couch that had recliners at each end. The recliner on the right side was in the reclined position. A dining chair was positioned behind the back of the recliner and was holding the back in a more upright position. When the chair was removed, the recliner back would not stay upright. During an interview on 10/24/2024, Licensed Practical Nurse (LPN) 1 and the Assistant Director of Nursing (ADON) stated that the couch had only been broken for a week. They were not sure if the maintenance department had been notified. During an observation on 10/25/2024 at 9:34 AM, the Orchard living room had a half-circle couch. There was a two-cup holder on the left-hand side of the couch. The metal liners for those cup holders were missing. One of the two cup holders had exposed wood that was rough to the touch and could cause injury to a residents' hands and/or fingers. During an interview on 10/25/2024 at 9:34 AM, the Activity Director thought the couch in the Transition wing had broken about a week ago. The AD stated that a request for items to be fixed would be entered in the TELS (Building Management System) and then maintenance would fix the item. During an interview on 10/25/2024 at 9:54 AM, the Maintenance Director revealed he had not been notified of the condition of the couches. He reviewed the TELS system and did not see where the two couches had been reported. He stated the Transition living room couch recliner was broken. Per the Maintenance Director, he had not been notified of the metal liners missing from the Orchard couch. During an interview on 10/25/2024 at 2:42 PM, the Director of Nursing (DON) and the Administrator stated that the Transition living room couch had been broken for about a week. Both stated they were unaware of the missing metal liners for the Orchard living room couch.

Based on observations, interviews, and facility policy review, the facility failed to properly store medications. Specifically, there were several loose tablets in three of six medication carts (Peach unit, Cherry unit and Maple unit). This failure increased the risk for drug diversion from three of six medication carts. The findings include: Review of the undated facility policy titled, Review of Unused Drugs revealed, All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements). Policy Explanation and Compliance Guidelines: 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements . During interview on [DATE] at 2:42 PM, with Licensed Practical Nurse (LPN)2 and observation of the Peach Unit medication cart, revealed when the drawers of the cart were opened there were two loose tablets (one round pink tablet and one round white tablet) in the first large drawer, three loose tablets (one pink round tablet, one round white tablet, and one green tablet) in the second large drawer, and three and a half tablets (partial white tablet, one round brown tablet, one oval pink tablet, and one round white tablet) in the third large drawer. LPN2 stated that when a nurse finds loose pills in the medication cart, they are to put them in the sharps container, otherwise the night nurse cleans out the carts on a routine basis and throws away any loose pills. LPN2 stated that she had not seen the loose tablets in the cart, and she did not know who they belonged to. During interview on [DATE] at 3:02 PM, with LPN3 and observation of the Cherry Unit medication cart, revealed when the drawers of the cart were opened there was one loose tablet (one round white tablet) in the first large drawer, and two loose tablets (one round white tablet and one oval tan tablet) in the second large drawer. LPN2 stated that whoever notices loose pills in the cart was responsible for discarding them in the sharps container. LPN2 stated that she had not seen the loose tablets in the cart, and she did not know who they belonged to. During interview on [DATE] at 03:29 PM, with LPN1 and observation of the Maple Unit medication cart, revealed when the drawers of the cart were opened there was one loose tablet (one round yellow tablet) in the first large drawer. LPN1 stated that she had not noticed the loose tablet, but the facility protocol was for any nurse finding loose pills should discard of them in the sharps container. Otherwise, the Medical Records nurse (MR) does cart audits once a week and discards any loose pills. During an interview on [DATE] at 2:28 PM, the Director of Nurses (DON) stated that the MR nurse does cart audits on Monday or Tuesday every week. The DON stated that her expectation was for any loose pills to be disposed of in the sharps container. Any nurse may dispose of loose pills in the sharps box, and they don't record this information. The facility has a new pharmacy consultant group, and they haven't done cart audits. Additionally, the DON did not think the facility had a policy that directly addressed medication storage. During an interview on [DATE] at 2:43 PM, the MR nurse confirmed that she performed cart audits on Mondays, but the last audit was on Sunday ([DATE]). She stated sometimes she finds loose pills, and sometimes she doesn't. Per the MR nurse, any nurse may dispose of loose pills in the sharps container when they find them. During an interview on [DATE] at 3:30 PM, the Administrator stated that she was aware that three of the six medication carts were observed having loose pills on [DATE]. She stated her expectation was for the MR nurse to do an audit at the beginning of the week to ensure the carts were clean and loose pills were disposed of. She felt that she had practical expectations and that from time-to-time pills were going to fall out of the blister packs. The Administrator stated when nurses see loose pills, the expectation was for them to destroy the medications, and any loose narcotic medications were to be given to the DON for destruction.

Based on interview, record review, and review of the facility instructions for completion of the Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) CMS-10055, revealed that the facility did not provide the SNFABN document to one of one resident (Resident (R)52) who remained in the facility after receiving skilled Medicare part A services. This failure could lead a resident or responsible party to not make an informed decision about remaining in the facility after Medicare A services ended. The findings include: Review of the directions for completion of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 directed, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial. The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must us the SNFABN when applicable for SNF Prospective Payment services (Medicare Part A). Review of R52's electronic medical record (EMR) revealed the Face Sheet located in the Profile tab indicated the facility originally admitted the resident on 05/09/2024 for therapy. The resident's last covered day (LCD) was 07/31/2024 and she remained in the facility for long-term care (LTC). The facility issued a Notice of Medicare Non-Coverage (NOMNC) on 07/29/2024 that was signed by her representative. She was not issued a SNFABN although she remained in the facility for LTC. R52 had 16 days of Medicare A remaining. Review of the Medicare Part A, PPS (Prospective Payment System) Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 07/31/24, completed at the end her of Medicare Part A services, revealed R52 had a Brief Interview of Mental Status score of 09 out of 15 which indicated R52 had moderately impaired cognition. During an interview with the Business Office Manager (BOM) on 10/24/2024 at 4:06 PM, she stated she was responsible for issuing the liability notices to residents whose Medicare A services were ending. When asked about the CMS-10055 SNFABN she stated, we give those to residents when their Medicare Part B services were ending. When asked if she had ever issued one to a resident who was coming off Medicare A services, her reply was no. She stated was unaware that a CMS-10055 SNFABN was required for Medicare A residents remaining in the building for long-term care. She stated the facility did not have a policy. Per BOM, the facility used the CMS directions to complete and issue the notices. A copy of the directions that she followed was requested. On 10/24/2024 at 4:30 PM, the BOM provided the directions for the CMS-10123 NOMNC however she did not provide a copy of the directions for the CMS-10055 SNFABN form. The Administrator provided two pages that she printed from the CMS website on 10/24/2024 at 5:00 PM and stated, We don't have to complete them until the end of the month because it is not mandatory yet.The surveyor reviewed the pages the Administrator printed and informed the the Administrator the CMS-1055 had been in use for years but CMS had recently revised the form to make it easier to understand and complete. Additionally, the pages printed were from the CMS website were in reference to the revised CMS-1055 and when they new form was to be used. The Administrator did not provide the directions for completion of the current version of the CMS-10055. Interview on 10/25/2024 at 10:00 AM, the Administrator made multiple attempts to stated that the SNFABN was not required if there was no expectation of liability for the resident. She stated the company that owned the facility until 11/01/2024 never went after bad debt and always wrote it off. During an interview on 10/25/2024 at 03:15 PM, the Administrator stated her expectation was that they were going to follow Medicare guidelines.

Based on record review, interviews, and policy review, the facility failed to verbally explain the contents of the binding arbitration agreement for one resident (Resident (R)24) of three residents reviewed for binding arbitration agreements. The findings include: Review of the facility's policy provided by the facility titled, Binding Arbitration Agreement dated 10/01/2022, revealed Policy Explanation and Compliance Guidelines: I. When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement. Review of R24's quarterly Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab and with an Assessment Reference Date (ARD) of 08/10/2024, revealed R24 was admitted to the facility with diagnoses of Alzheimer's disease with late onset, depression, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction. The MDS indicated R24 had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. During a telephone interview with R24's family member (F)1 on 10/24/2024 at 9:00 AM, he stated he had signed R24's binding arbitration agreement for the resident. F1 stated he did not recall anyone explaining the contents of the agreement to him. He stated that he wanted R24 to be admitted and that he signed whatever was presented to him. F1 stated he was unsure of what legal rights he was giving up by signing the arbitration agreement. During an interview on 10/23/2024 at 3:45 PM, the Admissions Director (AD) stated during the admission process, his process for obtaining a binding arbitration agreement was to ask the resident or their representative if they knew what the binding arbitration agreement was. If they say no, he goes on to explain that arbitration was when a serious allegation was filed against the facility,and it goes to arbitration. A neutral lawyer would be brought in to listen to both sides, to mediate and to come to a conclusion. The AD stated that he assured the resident that they would still be treated in the facility regardless of whether they signed the arbitration agreement or not. The AD stated he would ask if the resident or their representatives wanted to read through the binding arbitration document first and most of them said, no. The AD stated he never told residents or their representatives that they could take the arbitration to be reviewed by their attorney before signing but gave them a copy of the entire admission packet after they have signed. When asked if he told residents of their right to rescind the arbitration agreement before thirty days, he stated, No. The AD stated he did not know how many days residents had to rescind the arbitration agreement and that no one had ever told him about the resident's right to rescind nor did he inform residents of that right. The AD stated he did not inform residents of the right to a neutral choice of venue. The AD stated he was not aware that residents could not change their minds after thirty days had passed. During an interview with the Administrator on 10/25/2024 at 3:15 PM, she stated it was her expectation that the AD explains the binding arbitration agreement to residents before they sign.

Based on observation, interview, and policy review, the facility failed to ensure infection control practices had been followed by two of six staff (Licensed Practical Nurse (LPN)2 and LPN4) while dispensing medications for two of 11 residents (Resident (R)59 and R39) observed during medication administration. This deficient practices has the potential to contaminate the medications taken by the residents. The findings include: Review of the undated facility policy titled Medication Pass Procedure included, .medications were to have been opened without contamination. Wasted or dropped medication would have been destroyed and documented. During an observation on 10/23/2024 at 3:23 PM, while putting medications into plastic medication cups and filling a small plastic cup with water, LPN4 touched the inside of the medication and plastic cup. LPN4 proceeded to give R59 the medication cup and R 59 dropped a capsule from the cup onto her shirt. LPN4 picked up the medication and gave the capsule to R59 with her bare hands. During an observation and interview on 10/24/2024 at 3:41 PM, LPN2 stated that she used her fingernail to open the foil covering on the back of the blister pack before she pushed the medication out of the blister pack. LPN2 was observed to touch R39's blister packs with her fingernail and open the foil on the back of the pack for seven medications. During an interview on 10/25/2024 at 9:31 AM, LPN2 denied she had used her fingernail to open the foil covering before she pushed the medication out of the blister pack. During an interview on 10/25/2024 at 9:28 AM, LPN4 confirmed that she had touched the insides of the medication and water cups. Per LPN4, she knew she should not have touched the cups in that manner. LPN4 stated she should have used a glove or disposed of R59's capsule medication when it fell on R59's shirt. She stated she could have also asked the resident if she would have wanted to pick the pill up herself. During an interview on 10/25/2024 at 11:38 AM, Staff Development Nurse confirmed LPN2 and LPN4 had both failed to ensure infection practices during the medication passes. Staff Development stated each nurse had competency observations as part of their orientation and on an annual basis. During an interview on 10/25/2024 at 2:42 PM, the Director of Nursing (DON) revealed she was aware of the incidents by the nurses. The DON stated both LPN's breached infection control practices while passing medications.

Based on clinical record review, interview, and facility policy review it was determined the facility failed to make notification to the physician of change in condition for one (1) of four (4) sampled residents (Resident #1). Resident #1 had significantly elevated blood glucose levels identified. In addition, the facility failed to notify the physician when the resident's glucose levels exceeded the glucometer's ability to read a numerical number, and simply read HI, which indicated the resident's blood glucose was above 600 milligrams/deciliter (mg/dl). The findings include: Review of the facility's policy titled, Notification of Changes Policy, implemented 03/01/19, revealed the facility shall promptly notify the physician, or delegate of changes in the resident's condition, or status to obtain orders for appropriate treatment and monitoring to promote the right to make choices about treatment and care preferences. Nurses and other care staff were educated to identify changes in a resident's status and define changes requiring notification of the resident's physician, to ensure the best outcomes of care for the resident. Review of the Licensed Practical Nursing Scope of Practice in Kentucky revealed KRS (Kentucky Revised Statutes) 314.021(2) holds nurses individually responsible and accountable for rendering safe, effective nursing care to clients and for judgments exercised and actions taken in the course of providing care. Review of the Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association (ADA), volume 39, dated February 2016, revealed specific situations needed attention in patients with diabetes in the long-term care. The ADA recommended for long-term-care (LTC) staff to call the practitioner for any of the following glucose meter readings: Specifically with glucose meter readings >250 mg/dl with two (2) or more times within 24-hour accompanied by a new or change in medical or functional status. Glucose meter readings >300 mg/dl during all or part of two (2) consecutive days. In addition, any glucose reading too high to measure by the glucose meter. Review of Resident #1's clinical record revealed the facility admitted the resident on 06/27/19, with the [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED].= 0 insulin; 121-160 mg/dl = 1 unit of insulin; 161-200 mg/dl = 2 units of insulin; 201-240 mg/dl = 3 units of insulin; and, if greater than 240 mg/dl= 4 units of insulin. The sliding scale frequency was ordered before meals (ac) and hour of sleep (HS). The orders included Humalog three (3) units three times per day at 7:00 AM, 11:00 AM, and at 5:00 PM. Toujeo [MEDICATION NAME] Insulin 20 units every HS at 8:00 PM. However, further review revealed no documented evidence of guidance to staff as to how high the reading could be before notifying the physician for further guidance. Review of Resident #1's Grid Treatment/Assessment Report with Nursing Accu-check glucose monitoring, dated 12/16/19 at 9:00 PM, revealed the resident's glucose (blood sugar) level was 465 milligram/deciliter (normal range can vary between 100-140 mg/dl) Further review revealed the resident's glucose levels: on 12/17/19 at 7:00 AM was 422 mg/dl; at 11:00 AM it was 290 mg/dl; at 5:00 PM it was 522 mg/dl; and, at 9:00 PM it was 460 mg/dl. Again, on the morning of 12/18/19 at 7:00 AM, the resident's glucose read HI (which indicated it was above 600). Resident #1 had a fall two (2) hours later, and was sent to the hospital for a post fall evaluation. Upon request of the facility's policy for glucose monitoring, and interview with the Director of Nurses (DON), on 04/01/2020 at 12:16 PM, revealed the facility did not have a specific policy on Glucose Monitoring. She stated, We follow the physician's orders [REDACTED]. Review of the facility's Licensed Practical Nurse (LPN) job description, not dated, revealed the LPN was responsible for the direct and indirect nursing care of all patients experiencing medically complex conditions. Further review revealed the LPN demonstrates the knowledge, and skill to carry out the nursing process when patient care was provided. The LPN implements the patient care utilizing the care plan, delegates medical orders, and collaborates with the health team member, as necessary. The LPN documents the delivery of health care, and the nursing process in accordance with the specific unit standards. He/she knows the rationale for the effect of medications, treatments, and ensures they are correctly administered. Review of Resident #1's Admission Minimal Data Set (MDS), dated [DATE], revealed the facility assessed the resident, utilizing the Brief Interview for Mental Status (BIMS) with a score of ten (10), which indicated the resident was moderately impaired. Further review revealed the resident's active [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) with a score of thirteen (13), which indicated the resident was cognitively intact. Further review revealed the resident's active [DIAGNOSES REDACTED]. Review of Resident #1's Grid Treatment/Assessment Report with Accu-checks, on 12/16/19 at 9:00 PM, revealed his/her level was 465 mg/dl; on 12/17/19 at 7:00 AM it was 422 mg/dl; at 11:00 AM it was 290 mg/dl; at 5:00 PM it was 522 mg/dl; and, the glucose level at 9:00 PM was 460 mg/dl. Continued review of Resident #1's Grid Treatment/Assessment Report with Accu-checks, on 12/18/19 at 7:00 AM, revealed LPN #3 documented the glucometer read the blood glucose as HI; however, LPN #3 documented the HI reading as 500 mg/dl. Record review revealed no documented evidence the physician was notified of this extremely high blood glucose. Telephonic interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed the computer did not allow word entry when the glucometer read HI. Therefore, numerical documentation was required to proceed in the electronic medical record. She stated she documented 500 mg/dl because the glucometer never read higher than 500 mg/dl. She stated Resident's blood sugar, on 12/18/19 at 6:30 AM, read HI. LPN #3 stated the routine insulin and sliding scale coverage were administered. Review of Nurse's Notes (NN) documented by Licensed Practical Nurse (LPN) #3's, dated 12/18/19 at 9:10 AM, revealed Resident #1 was found face down at the foot of the bed with a laceration on his/her left temple. Continued review revealed the LPN placed a call to the physician, and received orders to send the resident to the emergency room for evaluation, and treatment. Further review revealed the NN, timed at 9:52 AM, revealed at 7:00 AM, the resident's blood sugar was HI, with sliding scale and routine insulin administered. Telephonic interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed she was familiar with Resident #1's care needs. She stated the resident was a diabetic, and very brittle with his/her blood glucose levels. She stated according to the documentation she provided care for Resident #1, on 12/16/19, 12/17/19, and 12/18/19. Upon further review of Resident #1's clinical record, dated 12/18/19, revealed no documented evidence of physician notification related to the resident's elevated blood glucose prior to the resident's fall (12/18/19). Continued telephonic interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed she provided care for Resident #1 per documentation, on 12/24/19 through 12/26/19. LPN #3 stated the glucometer read the resident's blood glucose as HI on 12/25/19 at 7:00 AM; on 12/26/19 at 7:00 AM, and on 12/26/19. She stated the computer did not allow word entry when the glucometer read HI. Therefore, numerical documentation was required to proceed in the electronic medical record. Continued interview with LPN #3, on 04/02/2020, at 2:30 PM, revealed the glucometers read up to 500 mg/dl. The LPN stated if the blood glucose levels were above 500 mg/dl, the glucometer simply read HI. She stated she documented HI in the order instructions section in the computer. LPN #3 stated the reading needed to be documented in the Nurse's Notes, so she documented 500 mg/dl. She stated the glucometers used in December were not the same ones as were being used currently The LPN stated, the prior glucometer read up to 500 mg/dl, she believed. Continued interview with LPN #3, on 04/02/2020 at 2:30 PM, and review of Resident #1's Grid Treatment/Assessment Report with Accu-checks, dated December 2019, revealed she followed the doctor's orders for the elevated glucose level of HI, on 12/18/19. LPN #3 stated the resident's glucose was higher than the 500 mg/dl, as the glucometer only was only capable of reading up to 500, if it was higher, it read HI. She stated she administered the four (4) units of sliding scale insulin dose for the glucose level greater than 240 mg/dl, and the routine insulin of three (3) units. LPN #3 stated she called the doctor, and received orders to send the resident to the emergency room for evaluation, and treatment. Further interview revealed the call to the doctor was related to the laceration secondary to the fall, and not related to the resident's HI glucose levels. Review of Resident #1 clinical record, revealed the resident was admitted to the hospital in the Intensive Care Unit (ICU), on 12/18/19, with the [DIAGNOSES REDACTED]. Resident #1 was discharged back to the facility, on 12/23/19. Review of Resident #1's physician's orders [REDACTED]. Further review revealed a second order for Humalog. In addition, Toujeo [MEDICATION NAME] Insulin was reordered on [DATE], with an adjustment with frequency, and dosage of 10 units subcutaneous, twice/day (BID), at 8:00 AM and 8:00 PM. Continued interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed she followed the physician's orders [REDACTED]. Further interview revealed she did the same thing on 12/25/19 at 7:00 AM when the resident's glucose level read HI and she documented it as 500 mg/dl. She stated she administered the four (4) units of sliding scale insulin dose for the glucose level greater than 240 mg/dl, and the routine insulin of three (3) units. Further interview revealed LPN #3 did not notify the physician of the HI blood glucose reading. Interview, on 04/02/2020 at 2:30 PM, with LPN #3 revealed the resident's blood glucose, on 12/25/19 at 11:00 AM, was 485 mg/dl. Further record review, revealed Resident #1's blood glucose, on 12/26/19 at 7:00 AM, read HI, and the LPN documented the numerical entry of 500 mg/dl, and the 11:00 AM, blood glucose remained the same, and she documented it the same. Further interview with LPN #3 revealed she did not have concerns that the physician was not notified related to the elevated blood glucose levels, as she had followed the physician's orders [REDACTED].#3 stated she stood by following the doctor's orders. She explained her process with glucose monitoring, was to obtain the blood glucose level via the glucometers, review the routine and sliding scale insulin, and administer the amounts as ordered. She stated she signed the insulin off on the Medication Administration Record [REDACTED]. She stated the computer did not have an area for her to document the amount of sliding scale insulin that was administered. LPN #3 stated she sometimes entered the routine and the sliding scale insulin on the Accu-checks, but not always. She stated she administered whatever was ordered based on the sliding scale. The LPN stated there was no documentation identifying the specific amount of insulin administered with the sliding scale. She stated she had no concerns with the resident's glucose levels exceeding the glucometers ability to read the accurate glucose level. LPN #3 stated she did not notify the physician of the elevated blood glucose readings. Telephonic interview with LPN #2, regarding Resident #1's clinical record, on 04/06/2020 at 5:10 PM, revealed she was familiar with Resident #1's care, and needs. She stated she worked the evening shifts routinely. LPN #2 stated Resident #1 would yell out when his/her blood glucose was running high. She stated Resident #1 had the tendency to be demanding when his/her blood glucose was high. The LPN stated the resident demanded cookies, and drinks, and was just very demanding in general, and rude. She stated she believed the resident had fallen a few days prior to this shift. LPN #2 stated she simply followed the physician's orders [REDACTED]. She stated she had orders for the sliding scale insulin, so she followed the doctor's orders. The LPN stated she always notified the physician of the elevated glucose levels. Further review of Resident #1's glucose levels, on 12/17/19 at 5:00 PM, revealed the resident's glucose was 522 mg/dl, and again at 9:00 PM, the level was 460 mg/dl. Initially, LPN #2 stated she notified the physician of the elevated glucose levels and she administered the ordered seven (7) units of ordered insulin. Upon further inquiry, LPN #2 stated the seven (7) units of insulin administered were the current orders of routine and sliding scale insulin. She stated she did not have any new orders. LPN #2 stated the orders and notification should be in the clinical record, and match the dates and times of the high glucose levels. However, there was no documented evidence that the LPN notified the physician. During interview, with LPN #2 and review of the glucose monitoring related to the 12/24/19 blood glucose readings of 600 mg/dl, and 571 mg/dl, she stated she relied on the orders in place, and administered the insulin, as ordered. LPN #2 stated she was sure she notified the physician, as she always did. Upon further review of the physician's orders [REDACTED].#2, she stated she did not have a total recall of a particular night. Continued review of Resident #1's physician's orders [REDACTED]. The Humalog sliding scale for blood glucose levels at the hour of sleep (HS) read 220 or less did not receive any insulin, 221-240 = 1 unit of insulin, and blood glucose greater than 240 = 2 units of insulin. The orders for the HS sliding scale insulin continued through 12/27/19. In addition, the resident was ordered, on 12/16/19, Toujeo [MEDICATION NAME] Insulin 20 units every HS at 8:00 PM. The insulin orders were updated after the resident's return from the hospital. Upon request of the facility's policy related to physician's orders [REDACTED]. [REDACTED]. Review of the facility's current Glucose Monitoring System User Instruction Manual, revised date January 2017, revealed when the monitor read HI, indicated the glucose level was more than six-hundred (600) milligrams (mg)/deciliter (dl). The instruction manual directed for a repeat test with a new test strip. If the HI message showed again, then contact your healthcare professional right away. Review of Resident #1 clinical record, revealed he/she was admitted to the hospital in the Intensive Care Unit (ICU), on 12/26/19, with the [DIAGNOSES REDACTED]. He/she was discharged back to the facility, on 12/31/19. Telephonic interview with LPN #6, on 04/08/2020 at 4:30 PM, revealed the facility was using the Assure Prism glucometers back in December. She stated she believed they read up to 500 mg/dl and if it was above 500 mg/dl, it read HI. She stated the order instructions were for documentation of any new physician orders [REDACTED]. LPN #6 stated the doctors must be notified of high blood sugars for additional insulin coverage when the glucose exceeded the ordered amount. She stated the doctor had to be notified of the HI glucose, since the nurses did not have orders to administer additional insulin, or new orders. LPN #6 stated she was unsure, and unable to recall the reason no documentation was added related to the 600 mg/dl glucose reading, on 12/13/19 at the 6:00 AM, accu-check. She stated she normally reported the levels to the physician, and documented the notification. Telephonic interview with the Director of Nurses (DON), on 04/01/2020 at 2:00 PM, and on 04/06/2020 at 9:30 AM, revealed the nurses followed the physician's orders [REDACTED]. She stated the sliding scale insulin orders should have parameters, and specifics of when to notify the physician. The DON stated the orders did not explain to staff when notification to physician should occur ,related to blood glucose readings. She stated the nurses followed the physician's orders [REDACTED]. The DON stated Resident #1 had not returned to the facility since the last hospitalization , and she was not aware of any ongoing issues related to the resident's glucose levels and physician notifications. Interview with the previous Director of Nurse (DON), on 04/08/2020 9:40 AM, revealed the staff followed the facility's policy related to notification of changes. She stated she and the clinical team reviewed the new orders, the staff shift reports, and they did not identify any concerns with glucose monitoring or physician notification. She stated she had not identified any concerns with any reviews of the orders related to the glucose monitoring; however, she did not complete any audits with blood glucose monitoring. The DON stated there was no tracking or trending of any glucose monitoring. She stated she had not identified any concerns; therefore, she had no reasons to take anything to the Quality Assurance and Performance Improvement (QAPI). Further interview with the DON revealed Resident #1's Diabetes was very brittle and his/her blood sugars were across the board and changed very rapidly. She revealed Resident #1's glucose levels were very high, and dropped rapidly. The DON stated she did not recall any time the physicians were not notified of the resident's high glucose levels and she only eyeballed the orders and notifications, without any research. She stated any blood glucose level exceeding five-hundred (500) mg/dl; the glucometer read HI. If the glucometer read HI, then notification to the MD/NP (medical doctor/nurse practitioner) for potentially new orders for laboratory orders, or insulin coverage. She stated she did not identify any concerns with Resident #1's admissions to the hospital related to his/her recurring admissions of Diabetic Ketoacidosis. Telephonic interview with Physician #1, on 04/06/2020 at 3:37 PM, revealed this physician was familiar, and followed the resident's care. Further interview revealed the medical group saw the resident multiple times for medical management of his/her Diabetes Mellitus (DM) type 2 over the past year. The physician stated the resident already had a previous history of Diabetic Ketoacidosis (DKA), and because of his/her non-compliance and refusal of care, there had been multiple episodes of hospitalization s over the course of his/her care. Further review of the glucose monitoring form for the month of December 2019, with the physician, revealed the physicians should have been notified of the resident's glucose levels when they exceeded the upper parameters of the sliding scale. She stated the elevated glucose levels should have been reported to the physician group for additional insulin coverage. Further interview revealed instructions had been given to the nursing staff, in the past, related to notifications of high blood glucose readings. She stated the sliding scale and routine orders were not sufficient to cover the blood glucose level exceeding the 400 mg/dl range. The physician stated that all of the high levels, ranging in the 400, 500, 600 mg/dl, and when the machine read HI required physician notification for further orders. The physician stated, Our medical group was not notified; otherwise, additional orders should correlate with the elevated blood glucose levels. She stated with notification of the elevated glucose levels, medically, there were opportunities to review potential underlying concerns, and prevent hospitalization s. Telephonic interview with Advance Practice Registered Nurse (APRN), on 04/06/2020 at 4:13 PM, revealed she followed Resident #1 in the facility. She stated the resident was a brittle Diabetic, with some non-compliance issues. She revealed she was not made aware of Resident #1's elevated blood glucose in December 2019. Continued interview revealed she was not notified that the resident's glucose levels were over 600 mg/dl. She stated any of the levels in the high ranges of 400, or above required immediate attention. According to the APRN, the glucometer was unable to read any amount above 600 mg/dl, it read HI. Therefore, if the glucometer read HI, the resident required medical interventions. She stated upon notification of elevated glucose levels new orders should reflect each of the high glucose levels with the times and date. Interview with the Administrator, on 03/31/2020, at 4:45 PM, revealed Resident #1 was fragile with his/her medical history. She was not aware there were any issues with physician notification related to the resident's care. She stated she was aware of several hospitalization s; however, the prior Director of Nurses (DON), never identified any concerns with the resident's glucose monitoring, or physician notification. She stated the prior DON never brought any of those concerns forward, or to the Quality Assurance and Performance Improvement (QAPI).

Based on clinical record review, interview, and facility policy review it was determined the facility failed to develop, and implement the comprehensive, person-centered care plan for one (1) of four (4) sampled residents (Resident #1). The facility failed to include approaches, and interventions to ensure staff were able to identify changes specific to the resident, and when to notify the physician. Staff identified the resident would exhibit behaviors of being very rude and demanding when his/her blood glucose levels were elevated. However, the facility failed to care plan interventions to address these behaviors. The care plan approaches gave direction to observe the resident for elevated blood glucose levels, but failed to give direction for follow-up when the resident's blood glucose was elevated. In addition, the care plan approaches for medications related to the resident's elevated blood glucose failed to define parameters, or when to notify the physician. The findings include: Review of the facility's policy, titled Comprehensive Care Plans, implemented 03/01/19, revealed the facility was to develop, and implement a comprehensive person-centered care plan for each resident. The care plan should be consistent with the resident's rights. The care plan should include measurable objectives and timeframes for the resident. The care plan should relate to their medical, nursing, mental, and psychosocial needs identified in the resident's comprehensive assessment. The comprehensive care plan should describe, at a minimum, the services furnished to attain, or maintain the resident's highest practical physical, mental, and psychosocial well-being. Review of Resident #1's clinical record revealed the facility admitted the resident, on 06/27/19, with the [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimal Data Set (MDS), dated [DATE], revealed the facility conducted a Brief Interview for Mental Status (BIMS) assessment and determined the resident was moderately impaired. Resident #1 scored ten (10) on the BIMS. Review of Section E200 revealed the facility assessed the resident's physical behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others as not exhibited by the resident. However, verbal behavioral symptoms directed toward others occurred one (1) to three (3) days. The facility assessed the resident in Section 800, rejection of care related to presence and frequency, revealed the resident exhibited rejection of care type of behavior on one (1) to three (3) days. Review of Section G related to functional status assessment revealed the resident required limited assistance with self-performance, and one-person physical assistant for support with toilet use. Section I included the active [DIAGNOSES REDACTED].#1 received seven (7) insulin injections during the look back period. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed his/her Brief Interview for Mental Status (BIMS) and scored thirteen (13), which indicated the resident was cognitively intact. Further review revealed the resident had improved since initial admission and was cognitively intact. Review of Section E200 revealed the facility assessed the resident's physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others as not exhibited by the resident. The facility assessed the resident in Section 800, rejection of care, with presence and frequency revealed the resident did not exhibit rejection of care behavior. Diabetes Mellitus remained an active diagnosis. Again, the insulin regime of seven (7) injections remained unchanged from the previous assessment. Review of the Behaviors Care Plan, Sequence #2, on-set date and reviewed 07/03/19, revealed the former MDS Nurse completed the care plan. The goal was for the resident to express criticism in a socially acceptable manner and no false accusations. The Behaviors Care Plan and the goal was last updated on 12/26/19. The approach or interventions included a psychological consult and the assist of two (2) persons with all care behind closed doors, and with all care, added on 08/22/19. Review of the Behaviors Care Plan, Sequence #22, on-set and reviewed 12/02/19, with two (2) goals identified. The first (1st) goal was decrease the number of episodes of resistance to care and participate in planned care by next review date. The second (2nd) goal revealed the resident would understand the need for and cooperate with care for ninety (90) days. The approaches (interventions) included to approach calmly and unhurriedly, document episodes of behaviors, introduce self (caregiver) and explain why care was needed, consistent caregivers, respect and encourage individuality, and notify medical doctor (MD) of changes in behaviors. Review of the facility's Licensed Practical Nurse (LPN) job description, not dated, revealed the LPN was responsible for the direct and indirect nursing care of all patients experiencing medically complex conditions. The LPN implements the patient care utilizing the care plan, delegated medical orders, and collaborates with the health team member, as necessary. The LPN documents the delivery of health care, and the nursing process in accordance with the specific unit standards. He/she knows the rationale for the effect of medications, treatments, and correctly administers. Performs, or supervises completed, timely, and accurate documentation of patient care. The LPN receives and provides shift report during each shift change. Interview with Certified Nurse Aide (CNA) #2, on 04/08/2020 at 1:50 PM, revealed Resident #1 did not require extensive care initially. She stated the resident was fragile. CNA #2 stated the resident yelled out for assistance when his/her call lights were not promptly answered. She stated he resident called out asking if anybody was out there, and would say, Hey I need help. CNA #2 stated she referred to the resident as a little snappy, and with an attitude. The CNA stated the resident told you what he/she wanted. CNA #2 stated the nurses never advised her about any concerns to observe, or report to the nurse. Further review of the Potential for Uncontrolled Blood Sugars, and Complications due to Diabetes Care Plan, Sequence #19, dated 10/16/19, revealed the care plan problem was last updated, on 01/02/2020. The goal for the resident was to not have signs or symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] for ninety (90) days; last-updated 12/26/19. The approaches included administer medications as ordered, and observe for symptoms of [DIAGNOSES REDACTED] which included sweating, headache, light-headedness, confusion, and drowsiness, dated 11/27/19. The approaches included observe for symptoms of [DIAGNOSES REDACTED] such as thirst, nausea or vomiting, weakness, confusion, fruity odor on breath, dated 10/23/19. The notes on the care plan, dated 12/04/19 included the order on 12/04/19, to give four (4) units of Humalog Insulin subcutaneous now, and recheck blood glucose in one (1) week. Interview with Licensed Practical Nurse (LPN) #2, on 04/06/2020 at 5:10 PM, revealed the care plans were resident specific. She explained she had to look at the care plans for any details related to the residents. LPN #2 stated Resident #1 experienced confusion with low blood glucose levels. She stated the resident was pretty nice when his/her glucose levels were in a good range. LPN #2 stated Resident #1 was rude and very demanding when his/her blood glucose levels were high. She stated the nurses could all update the care plans, but she never really updated the care plans. Further interview revealed the changes in personality with the elevated blood glucose levels were significant to this resident. LPN #2 stated the change in personality defined when the resident was hypoglycemic or hyperglycemic. She stated the care plan was never accurately developed for the needs of Resident #1 with his/her blood glucose monitoring, or when notification of physician should occur. Telephonic interview with Licensed Practical Nurse (LPN) #5, on 04/03/2020 at 3:35 PM, revealed she was not familiar with Resident #1's care plan. She stated she was seldom assigned to the hall where Resident #1 lived. She stated in the shift report she was not told anything related to Resident #1's elevated blood glucose levels, nor any information about speaking with the physician. She stated she did not recall if the care plan addressed the resident's diabetes, or the accu-check, as she seldom worked that hall. She stated she was sure the resident had a care plan in place for the non-compliance and his/her Diabetes Mellitus. Telephonic interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed she was familiar with Resident #1's care needs and his/her care plan. She explained the care plans were for direction on how to care and provide each resident's needs. The LPN stated she never updated the resident's care plan, the DON, or the MDS Nurse updated the care plans. She stated the MDS Nurse developed the care plan. Additionally, she stated she followed the doctors' orders more specifically than the care plan. LPN #3 stated her primary direction was to follow the doctor's orders and she knew the care plan was available. Telephonic interview with Licensed Practical Nurse (LPN) #6, on 04/08/2020 at 4:30 PM, revealed the Minimum Data Set (MDS) Nurse developed and updated the care plans. She stated she was never asked for input by anyone developing the care plans. The LPN stated she was never contacted during her shifts about any resident to obtain specific information for ensuing the care plan was resident specific. She stated the care plan should be specific to each resident's needs for the person-centered care plan. Further interview revealed the care plan should be a guide to the resident's care with details ensuring the resident was the best they could be. She stated, Our care plans are vague and without details. Telephonic interview with the Director of Nurses (DON), on 04/01/2020 at 2:00 PM, and on 04/06/2020 at 9:30 AM, revealed she began her position nearly six (6) weeks ago. The DON stated upon her discussions with the nurses, she identified that the nurses were not updating the care plans. She stated her understanding was the Minimum Data Set (MDS) Nurse updated the care plan, during the morning clinical meetings. The DON stated the care plans were not developed to the extent needed to define the resident's needs. Telephonic interview with the prior Director of Nurses (DON), on 04/08/2020 at 9:40 AM, revealed the care plans were reviewed during the clinical meeting. She stated the MDS Nurse updated the care plans. Further interview revealed the new orders were reviewed and the care plan was updated accordingly. She stated, Without orders we did not have a reason to review the care plan. She explained that the nurses working the unit did not update the care plans. The Prior DON stated she was not aware of the extent of the discussion between the unit nurses and the MDS Nurse with care plan updates. She revealed she was unable to recall any ongoing audits on the care plans. Interview with the Administrator, on 04/08/2020, at 6:15 PM, revealed the Prior DON never brought any concerns forward related to the care plans. She stated there were clinical meetings when the care plans were reviewed and updated. She stated she was aware Resident #1 was medically fragile. She stated she had identified some concerns related to the lack of audits related to care plans, glucose monitoring, and physician reporting. However, these issues were becoming known and now moving forward.

Based on clinical record review, interviews, and facility policy review it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received quality of care and treatment in conjunction with nursing professional standards with glucose monitoring. The facility assessed Resident #1, to be a brittle diabetic and had significantly elevated blood glucose levels. The resident received scheduled and sliding scale insulin. Resident #1's glucose levels before meals and at bedtime exceeded the sliding scale perimeters. Glucose levels were greater than 400 mg/dl, and some levels exceeded the glucometer's capability to read. The glucometer read HI. The facility failed to notify the physician with elevated blood glucose levels and continued to administer inadequate insulin dosages. The findings include. Review of the Licensed Practical Nursing Scope of Practice in Kentucky revealed KRS (Kentucky Revised Statutes) 314.021(2) imposes individual responsibility upon a nurse to undertake the performance of acts for which the nurse is educationally prepared and clinically competent to perform in a safe, effective manner. This section holds nurses individually responsible and accountable for rendering safe, effective nursing care to clients and for judgments exercised and actions taken in the course of providing care. The Standard of Care should be provided in similar circumstances by reasonable and prudent nurses who have similar training and experience. The State Survey Agency requested the facility's policy related to Glucose Monitoring. Interview with the Director of Nurses (DON), on 04/01/2020 at 12:16 PM, revealed the facility did not have a specific policy on Glucose Monitoring. She stated, We follow the physician's orders [REDACTED]. Review of the facility's policy titled, Notification of Changes Policy, implemented 03/01/19, revealed the physician, or delegate notification should occur promptly of changes in the resident's condition, or status to obtain orders for appropriate treatment and monitoring. Request of the facility's policy related to Physician order [REDACTED]. Interview with the Director of Nurses (DON), on 04/01/2020 at 2:00 PM, revealed the facility did not have a policy related to physician's orders [REDACTED]. [REDACTED]. Review of the Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association (ADA), volume 39, dated February 2016, revealed specific situations needed attention in patients with diabetes in long-term care. Specifically with glucose meter readings >250 mg/dl with two (2) or more times within 24-hour accompanied by a new or change in medical or functional status. Glucose meter readings >300 mg/dl during all or part of two (2) consecutive days. In addition, any glucose reading too high to measure by the glucose meter were all recommended for long-term-care (LTC) staff to call the practitioner. The ADA recommended an increase in the frequency of glucose monitoring, confirmation of high glucose value by laboratory testing, evaluate nutrition, and consider medical evaluation for other causes if glucose levels remained persistently high. Review of Resident #1's clinical record revealed the facility admitted the resident, on 06/27/19, with the [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimal Data Set (MDS), dated [DATE], revealed the facility assessed his/her Brief Interview for Mental Status (BIMS) with a score of ten (10) which indicated the resident was moderately impaired. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed his/her Brief Interview for Mental Status (BIMS) with a score of thirteen (13), which indicated the resident was cognitively intact. Review of Resident #1's Grid Treatment/Assessment Report with Nursing Accu-check glucose monitoring, dated 11/03/19, revealed a low glucose level of thirty (30) mg/dl, normal range 80-100 mg/dl. The accu-check report, dated 11/17/19 at 7:00 AM, revealed the glucose level was fifty-six (56). In addition, the location for documentation of the sliding scale insulin administered remain blank. Review of the notes dated 12/01/19, revealed the 4:00 AM, 7:00 AM, 5:00 PM and 9:00 PM insulin dosages were not documented in the clinical record. Review of notes dated 12/02/19, revealed the resident's glucose level dropped to forty-two (42) at 4:00 AM, and continued low reading of eight-seven (87) at 7:00 AM. However, the documentation remained inconsistent related to the amount of insulin administered to the resident with each sliding scale. Review of the Endocrinologist (diabetic specialist) visit assessment, dated 12/03/19, revealed the resident received very inconsistent insulin delivery from staff. Review of examples documented on the encounter notes revealed seven (7) units of insulin was administered for blood glucose of 278 mg/dl; two (2) units for glucose of 418 mg/dl; and no insulin administered for a glucose level of 555 mg/dl. Further review of documentation revealed the Endocrinologist spoke with the nursing staff and they reported they had a hard time giving the insulin, as they were scared to give insulin related to low blood sugar. Additionally, the Endocrinogist's notes stated the facility only gives two (2) units of insulin at bedtime. Review of Resident #1's Accu-checks, dated 12/02/19 at 9:00 PM, revealed his/her glucose was 485 mg/dl; however, the facility administered sliding scale Humalog Insulin, two (2) units for blood sugar greater than 240 = 2 units of insulin. Review of the Accu-check monitoring revealed the resident consistently ran exceedingly high glucose levels. Review of Resident #1's Physician order [REDACTED].= 0 insulin, 121-160 mg/dl = 1 unit of insulin, 161-200 mg/dl = 2 units of insulin, 201-240 mg/dl = 3 units of insulin, if greater than 240 mg/dl= 4 units of insulin. The sliding scale frequency was ordered before meals (ac) and hour of sleep (HS) at 9:00 PM was as follows: blood sugar less than 220 mg/dl = 0 units of insulin; 221-240 mg/dl = 1 unit of insulin; greater than 240 = 2 units of insulin. The routine orders included Humalog three (3) units three times per day at 7:00 AM, 11:00 AM, and at 5:00 PM. Toujeo [MEDICATION NAME] Insulin, ordered 12/15/19, was for 20 units subcutaneous every HS at 8:00 PM. Review of Resident #1's Grid Treatment/Assessment Report with Accu-checks, on 12/16/19 at 9:00 PM, revealed his/her blood glucose level was 465 mg/dl. Review of the Accu-check, dated 12/17/19 at 5:00 PM, revealed it was 522 mg/dl, and remained elevated; at 9:00 PM it was 460 mg/dl. Further review of Resident #1's clinical record, revealed no documented evidence of physician notification related to the resident's elevated blood glucose during LPN #2's shift, on 12/16/19 or 12/17/19. Review of Resident #1's Grid Treatment/Assessment Report with Nursing Accu-check glucose monitoring, on the morning of 12/18/19 at 7:00 AM, revealed the resident's glucose read HI. Review of the Nurse's Notes revealed the resident had a fall two (2) hours later. The resident was transferred to the hospital for a post fall evaluation. Resident #1 was admitted to the Intensive Care Unit (ICU), and remained in the hospital 12/18/19 through 12/23/19. Resident #1 returned to the facility on [DATE]. Review of Licensed Practical Nurses (LPN) #3's Nurses Notes (NN), dated 12/18/19 at 9:10 AM, revealed she heard Resident #1 call for help. Further review revealed she observed the resident with his/her face down toward the end of the bed with a laceration on his/her left temple. The resident's blood sugar noted at 6:30 AM, read HI. Further review revealed the regular ordered insulin and sliding scale insulin coverage were administered. A call was placed to the physician, and orders received to send the resident to the emergency room for evaluation, and treatment. Further review of the clinical record revealed the resident returned from the hospital on [DATE]. Review of Resident #1's Physician order [REDACTED]. However, the glucose perimeters exceeding the sliding scale orders were not clarified with the physician upon the resident's readmission to the facility. Further review of Resident #1's clinical record revealed the resident's blood glucose documented by LPN #3, on 12/24/19 at 7:00 AM was 565 mg/dl, and at 11:00 AM the glucose level was 500 mg/dl. Again, on 12/25/19 at 7:00 AM, the resident's glucose level read HI; however, the staff documented the reading as 500 mg/dl. Resident #1's blood glucose, on 12/25/19 at 11:00 AM, was 485 mg/dl and, on 12/26/19 at 7:00 AM, it read HI, and was documented as 500 mg/dl, and again, at 11:00 AM. Telephonic interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed she was familiar with Resident #1's care needs. She explained her process with glucose monitoring, was to obtain the blood glucose level via the glucometers, review the routine and sliding scale insulin, and administer the amounts as ordered. She stated she signed off on the Medication Administration Record [REDACTED]. LPN #3 stated the computer did not have an area to document the amount of insulin administered per sliding scale. She stated she sometimes entered the routine and the sliding scale insulin on the Accu-check documentation, but not always. LPN #3 stated the computer did not allow word entries when the glucometer read HI. The LPN stated the HI reading required documentation in the Nurses' Notes, and that was why she documented the word HI in the order instruction on the computer. She stated there was no documentation identifying the specific amount of insulin that was administered related to the sliding scale perimeters. Continued interview with LPN #3, on 04/02/2020 at 2:30 PM, revealed upon reviewing her documentation, she determined she provided care for Resident #1 on 12/16/19 through 12/17/19. She stated she sent the resident out to the hospital and cared for the resident after the resident returned from the hospital, on 12/24/19 through 12/26/19 during her shifts. LPN #3 stated the resident was Diabetic, and brittle with his/her blood glucose levels. She stated blood glucose level required numerical documentation. LPN #3 stated, the prior glucometer read up to 500 mg/dl, she believed. During continued interview and review of Resident #1's Grid Treatment/Assessment Report with Accu-checks, dated December 2019, the LPN stated she followed the doctor's orders for the elevated glucose level that read HI on 12/18/19. LPN #3 stated the resident had routine insulin and the sliding scale insulin ordered. She stated she called the doctor, and sent the resident to the hospital. However, further interview revealed the call to the doctor occurred after the resident's fall, not because of the elevated blood glucose. The LPN stated that on 12/24/19 at 7:00 AM, the resident's glucose was 565 mg/dl and at 11:00 AM the glucose level was 500 mg/dl and these readings were not unusual for the resident. Interview with LPN #3, on 04/02/2020 at 2:30 PM revealed she did the same, on 12/25/19 at 7:00 AM, with the glucose level of HI, with the documented level of 500 mg/dl. She stated the blood glucose, on 12/25/19 at 11:00 AM, was 485 mg/dl. Further interview and record review, revealed Resident #1's blood glucose, on 12/26/19 at 7:00 AM, read HI, and she listed the numerical entry of 500 mg/dl. LPN #3 stated she did not have concerns with additional notification to the physician, as she followed the orders. She stated she stood by following the doctor's orders. LPN # 2 documented Resident #1's blood glucose level, on 12/24/19 at 5:00 PM, was 600 mg/dl with seven (7) units of insulin administered (routine plus sliding scale). The blood glucose remained elevated at 9:00 PM, with the blood glucose level at 571 mg/dl. Continued review revealed on 12/25/19 at 5:00 PM, the level was 351 mg/dl; and at 9:00 PM, the blood glucose was 451 mg/dl. Continued accu-check reviewed, on 12/26/19 at 5:00 PM, the blood glucose level was 600 mg/dl. Telephonic interview with LPN #2, on 04/06/2020 at 5:10 PM, revealed she was familiar with Resident #1's care, and needs. She stated she had access to the residents' clinical record during this interview. The LPN stated Resident #1 got demanding and rude, and would yell out when his/her blood glucose were high. She stated she simply followed the physician orders [REDACTED]. Initially, she stated she notified the physician of the elevated glucose levels, that she always notified the physician of the elevated glucose Upon further inquiry, she stated any new orders should be in the clinical record, and the physician notification documented in the notes. However, further review revealed no documented evidence the physician had been notified. The LPN stated she may just forgot to document the notification. Continued review, of the clinical record with LPN #2 of the glucose monitoring related to her shift, on 12/24/19 at 5:00 PM, revealed the resident's glucose level was 600 mg/dl, and at 9:00 PM it was 571 mg/dl. Again, she stated she relied on the orders in place, and administered the insulin, as ordered. She stated the resident's blood sugar was above 240 mg/dl, with this being the upper amount of sliding scale insulin so she administered the insulin dosage for this level. LPN #2 stated the resident's glucose, on 12/26/19 at 5:00 PM, was 600 mg/dl, and she administered the insulin coverage the resident had ordered for glucose above 240 mg/dl. She stated she was sure she notified the Doctor, as she always did. Upon further review of the physician's orders [REDACTED].#2, she stated she could not remember. Telephonic interview with LPN #6, on 04/08/2020 at 4:30 PM, revealed the process of routine insulin administration documentation was on the Medication Administration Record [REDACTED]. She explained the MAR indicated [REDACTED]. She stated upon notification of out of range or high glucose levels, the new physician orders [REDACTED]. Further interview revealed the facility was using the Assure Prism glucometers back in December 2019. She stated she believed they read up to 500 mg/dl and above 500 mg/dl, they read HI. LPN #6 stated she was unsure, and unable to recall the reason for the lack of documentation and notification related to Resident #1's elevated glucose reading, on 12/13/19 at the 6:00 AM, with a reading of 600 mg/dl. She stated she normally reported the levels to the physician, and documented the notification. The LPN stated it was essential to let the doctor know about the high glucose for more insulin. Review of the Assure Prism Reference Manual, revealed the meter-displayed results twenty (20) to six-hundred (600) mg/dl. The HI message appeared when the blood glucose level was greater than 600 mg/dl, indicated severe [MEDICAL CONDITION]. Upon retesting with the results of HI revealed contact with the healthcare provider immediately. Interview with Licensed Practical Nurse (LPN) #5, on 04/03/2020 at 3:35 PM, revealed she provided care for Resident #1, on 12/26/19, and sent the resident to the hospital. She stated she and the aid were in the hallway discussing the residents when they heard Resident #1 asking for help. She stated she could see the resident was in distress and his/her oxygen levels were really low, and the resident was cold. LPN #5 notified the physician and orders were received to transfer the resident to the hospital emergency department for evaluation. According to LPN #5, she had not received any information in shift report regarding the resident's elevated glucose levels. She stated she was not made aware of the resident's high glucose levels on the previous shift. LPN # 5 stated the resident was fragile with his/her Diabetes; which required closer monitoring. She stated managing the glucose levels with the doctors should prevent the resident from having to go out to the hospital for the high glucose levels. The LPN stated the elevated glucose levels should be shared during report, so staff would know what to watch for with the resident. She stated the HI glucose level should be reported in order to provide care, and staff could notify the physician. Telephonic interview with the Director of Nurses (DON), on 04/01/2020 at 2:00 PM, and on 04/06/2020 at 9:30 AM, revealed she came to the position approximately six (6) weeks ago. She stated that once she identified the facility was utilizing other residents' glucometers on all of the residents, she had a concerns with this practice. She stated she implemented that each resident was assigned his/her own glucometer. The DON stated the sliding scale insulin orders should have parameters, and specifics of when to notify the physician. She stated the current orders did not explain/detail when physician notification should occur. The DON stated the nurses followed the physician's orders [REDACTED]. She further explained she was not aware of any ongoing issues related to the resident's glucose levels and physician notifications prior to this time. She stated the sliding scale insulin orders should have parameters, and specifics of when to notify the physician Interview with the previous Director of Nurse (DON), on 04/08/2020 at 9:40 AM, revealed she reviewed all resident hospital transfer. She stated they also discussed the hospital transfers during the clinical meeting. The DON stated she had not identified any concerns related to monitoring blood glucose levels. She stated that if the glucometer readings exceeded the sliding scale amounts, or read HI, then the physician should be notified for further orders. She stated by not actually auditing the glucose levels and the physician orders, she was unable to identify the issues. The DON stated the lack of physician notification, and lack of the close monitoring was not providing quality care to the resident. Telephonic interview with Physician #1, on 04/06/2020 at 3:37 PM, revealed this physician was familiar with Resident #1, and medically managed this resident. She revealed the resident had a history of [REDACTED]. She stated the resident's medical complexity related to his/her Diabetes, lead to the referral to an endocrinologist. Physician #1 stated she did not review the resident's individual glucose monitoring by the staff. Upon further review of the facility's glucose monitoring during December 2019, with the physician, revealed notification of glucose levels exceeding the upper parameters of the sliding scale were not reported for additional insulin coverage. She stated the staff were instructed to notify the physicians of such readings in the past. She stated the sliding scale and routine orders were not sufficient to cover the blood glucose level exceeding the 400 mg/dl range. All of the high levels above 400 mg/dl, mg/dl, and the machine read HI required physician notification for further orders. Further interview revealed no physician ignored high glucose levels upon notification. She stated, Our medical group was not notified; otherwise, additional orders should correlate with the elevated blood glucose levels. She stated with notification of the elevated glucose levels, medically, there were opportunities to potentially prevent hospitalization s. She stated the care was not of quality standards. The facility was not reporting the glucose levels to best serve this resident. Telephonic interview with Advance Practice Registered Nurse (APRN), on 04/06/2020 at 4:13 PM, revealed she followed Resident #1 in the facility. She stated the resident was brittle with his/her glucose levels. She stated she did not recall nursing staff notifying her related to elevated glucose levels. Upon review of Resident #1's blood glucose per accu-check documentation, dated December 2019, and interview related to the elevated glucose levels revealed the ARPN had not been made aware of the resident's high glucose levels. The ARPN stated any of the levels in the high ranges, higher than 400 and/or the reading of HI, needed immediate attention, with additional orders. Interview with the Administrator, on 03/31/2020, at 4:45 PM, revealed the facility had a clinical meeting each morning for discussion of concerns from the day before, any ongoing issues, and identified new concerns. She stated she was not aware there were any issues with physician notification related to resident care needs. Further interview revealed she was aware Resident #1 had several hospitalization s and had a fragile medical history. She stated the prior DON never brought any concerns forward related to the glucose levels and physician notifications. Telephonic interview with the Medical Director, on 04/07/2020 at 4:15 PM, revealed he was not the resident's physician; however, the facility requested he complete a review of Resident #1's clinical record, and his/her co-morbidities. He stated he reviewed the resident's discharged information from the hospitalization s and was aware of the problem related to the overall diabetic management with marked [MEDICAL CONDITION]. Upon further review of the blood glucose monitoring completed by the facility revealed the resident failed to receive adequate insulin coverage based upon the continued glucose levels above four-hundred (400). He further stated the glucometers read up to the six-hundred (600) range, so any glucometer reading HI, should absolutely be called to the physician. The Medical Director stated Resident #1's blood glucose levels were not well managed by the facility. He stated each of the elevated glucose levels needed physician notification. Continued interview revealed readings of HI did not define the glucose level for accurate dosing of insulin. He stated upon further review of the clinical record, the blood glucose levels were not adequately reported to the physician. He stated Resident #1 did not receive a quality of care, or treatment for [REDACTED].

Based on observation, interview and review of the facility's policies, it was determined the facility failed to store foods in accordance with professional standards for food service safety. Observations of the kitchen on 06/29/19 revealed frozen food products, outside original boxes without labels with food names, received dates, or use by dates. The findings include: Review of the facility's policy titled Date Labeling for Food Safety, revised 03/01/19' revealed the facility would adhere to a date marking system to ensure the safety of food. Additional review revealed food should be clearly marked to indicate the date or day by which food should be consumed or discarded by the individual opening a food. Continued review revealed the marking system consist of color-coded labels, the day/date of opening, and the day/date the item should be consumed or discarded. Further, the cook was responsible for checking the food items for expiration, and discarding accordingly; the Dietary Manager was responsible to spot check weekly for compliance. Observations of the walk-in freezer, on 06/29/19 at 12:40 PM revealed two (2) bags of frozen broccoli, with no food name label and no opening or consumed/discarded day/date. Further observations revealed one (1) bag of frozen breaded meat patties, one (1) bag of frozen peas, and one (1) bag of frozen diced chicken cubes, with no food name label and no opening or consumed/discarded day/date. Interview with Dietary Manager, on 06/25/19 at 12:44 PM revealed the Cook completed an audit tool daily, which included checking stock for correct labeling. Per interview, the Dietary Manager made daily rounds in the kitchen to validate the Cooks audit was completed accurately. However, the current audit system did not identify concerns with frozen food item and she could not state where the failure of the audit process was. Continued interview revealed, once a food product was removed from the original package a label should be added to the food to include the food name, open date and use by date. Further, it was important to have food products labeled per the facility policy to ensure food was safe for use per food standards. Interview with Cook #1, on 06/27/19 at 3:14 PM revealed when a food product was opened or take out of the original box a label should be added to the bag with the food name, the open date and the date the food goes bad. Additionally, she would look at all food items at least twice a day to ensure they were labeled per the facility policy. Further, it was important to know what food items were and what dates they were good until, to ensure residents were given the right food and the food was not bad. Interview with Administrator, on 06/28/19 at 10:15 AM revealed her expectation for food storage and labeling was for food products in the freezer to be labeled with a common food name and dated with a receive date, open date, and expiration date. Per interview, the Dietary Manager was to ensure facility policy was maintained. Additionally, the Administrator performed walk thoughts to ensure food was labeled in accordance to facility policy. Further, it was important food products were labeled accordingly to ensure foods served to Residents was safe food and meet their nutritional needs.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Observations revealed three (3) of five (5) medications carts to contain opened medications without labels or expiration dates. The findings include: Review of the facility's policy, titled Medication Storage, implemented on 03/01/19, revealed the facility would ensure all medications would be stored in accordance to the manufacturer's recommendations. Observation of the Transitional unit Medication Cart #1, on 06/26/19 at 8:45 AM, revealed the following items located in stock and available for resident use: one (1) Humalog (insulin) Pen, with no open date, or expiration date; one (1) [MEDICATION NAME] Nasal Spray, with no open date, or expiration date; and one (1) [MEDICATION NAME] Nasal Spray, with no open date, or expiration date. Interview with Licensed Practical Nurse (LPN) #1, who was assigned to Transitional unit Medication Cart #1, on 06/26/19 at 9:00 AM revealed all multi-dose medications should be dated with an open and/or an expiration dated, by the nurse who opens the medication. Per interview, dating a multi-dose medication ensures all nurses know when a medication would expire and when to not use the medication. Additionally, it was important to administer medications safely to residents because medication should have the therapeutic effect. Continued interview revealed the Unit Manager and a staff from the Pharmacy audited the medication carts periodically to ensure medication were stored appropriately. Further, she was responsible to ensure medications were labeled with open dates and expiration dates before administering the medication, when the medication cart was assigned to her. Observation of the Apple Orchard unit Medication Cart #2, on 06/26/19 at 9:40 AM, revealed the following items located in stock and available for resident use: one (1) Vial of [MEDICATION NAME] (insulin), with no open date, or expiration date. Interview with LPN #2, who was assigned to Apple Orchard unit Medication Cart #2, on 06/26/19 at 9:45 AM revealed all multi-dose vials of insulin should be dated with an expiration date to ensure the resident received medication not expired. Additionally, the assigned nurse was responsible to ensure all multi-dose medications were dated with opened and/or expiration dates. Further, expired medication would not have the most therapeutic effect. Observation of the Peach Orchard unit Medication Cart #3, on 06/26/19 at 9:50 AM, revealed the following items located in stock and available for resident use: two (2) [MEDICATION NAME] (insulin), with no open date, or expiration date; two (2) Humalog (insulin) Pens, with no open date, or expiration date; two (2) Baslar (insulin) Pens, with no open date, or expiration date; one (1) Levimir (insulin) pen, with no open date, or expiration date; two (2) [MEDICATION NAME] inhalers, with no open date, or expiration date; one (1) [MEDICATION NAME] HFA inhaler, with no open date, or expiration date; two (2) [MEDICATION NAME] salmeterol inhalers, with no open date, or expiration date; one (1) Lantaprost eye drop, with no open date, or expiration date; and one (1) [MEDICATION NAME] polymyixin eye ointment, with no open date, or expiration date. Interview with LPN #3, who was assigned to Peach Orchard unit Medication Cart #3, on 06/26/19 at 10:00 AM revealed, he/she was responsible to ensure multi-dose medications were labeled with open dates when assigned to the medication cart. Continued interview revealed nursing leadership also audited medication carts for proper medication storage and labeling routinely. Further, it was important that medications were administered to residents' safely and not expired to decrease the risk for adverse reactions. Interview with LPN #4, Unit manager of the Transition unit, on 06/26/19 at 9:15 AM revealed she expected medications to be stored per the facility policy and standards of practice. Additionally, all multi-dose mediations should be dated when opened by the assigned nurse. Per interview, she completed medication storage audits yesterday and did not identify any concerns. Further, she missed the medications that did not have open dates. Interview with LPN #5, Unit Manager Orchard, on 06/27/19 at 3:37 PM revealed when medications came in the facility from the pharmacy, the nurse assigned to the medications cart was responsible to label all medications with an open date. Per interview, eye drops, inhalers and insulins were multi-dose medications and required an open date and/or an expiration date. Additionally, it was important to know open dates and expiration dates of medications, to ensure medications were administered safely. Continued interview revealed she did not have a process in place to audit behind the floor nurses to ensure multi-dose medications were dated with open and expiration dates. Further, she was uncertain of the facility policy but expected nurses to know the facility policy and store and label medications appropriately. Per interview, all multi-dose medications identified during state inspectors observations of the Orchard Medication carts should have been labeled and dated per facility policy. Interview with Director of Nursing (DON), on 06/27/19 at 4:02 PM revealed multi-dose medications were dated when put on medication carts with an open date or expiration date, per facility policy. Per interview, audits of the medication carts for proper storage and labeling per facility policy was not currently completed. However, it was important to store and label medication appropriately to ensure standards of practice was maintained for medication administration. Additionally, proper labeling of medication would decrease the risk for administration of expired medications. Continued interview revealed expired medications would not have the most beneficial effect for the residents. Further, she expected all multi-dose medications identified by the state inspector, on the medication carts, to be labeled with open dates and expiration dates. Interview with Pharmacy Consultant, on 06/27/19 at 4:45 PM revealed the she had identified there was a need for correction at the facility earlier in the month, related to date opening on multi-dose mediations. Additional interview revealed a plan of action to implement correction was in progress for next month. Per interview, it was important for medications such as insulin, eye drops and inhalers to be dated with open dates to ensure sterility of the medications and to keep the product close to manufacturing standards. Interview with Administrator, on 06/28/19 at 10:24 AM revealed medication should be stored, labeled, and dated per facility policy. Per interview, multi-dose medication should have open dates and/or expiration dates on them once they are in the medication carts. Additionally, nursing staff should maintain the facility policy and process; each medication should have an open date and expiration date. Further, it was important for residents to receive medication that were not expired to ensure the have the most therapeutic effect from their medications.

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for one (1) of eighteen (18) sampled residents (Resident #77). Resident #77 had a urinary catheter; however, review of the Comprehensive Care Plan revealed no documented evidence of a plan of care for the urinary catheter. Review of Resident #77's physician's orders [REDACTED]. The findings include: Review of the facility's Policy Care Plan Revisions Upon Status Change, implemented 03/01/19, revealed the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Per the policy, the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Continued review revealed upon identification of a change in status, the nurse would notify the MDS coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Further review revealed the Care Plan would be modified as needed by the MDS Coordinator or other designated staff member. Additional review revealed the Unit Manager or other designated staff member would communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted and if so, the assessment will be completed according to established procedures. Record review revealed the facility admitted Resident #77 to the facility on [DATE]. Resident #77 had diagnoses, which included Dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Continued review of the record revealed the facility assessed Resident #77 per the most recent MDS assessment, and annual assessment, dated 04/16/19, as having a Brief Interview Mental Status (BIMS) score of thirteen (13) out of fifteen (15), the resident was assessed as always incontinent of urine and bowel, and was not assessed as having a urinary catheter at the time of the assessment. Record review revealed a Comprehensive Care Plan for Resident #77 with a problem onset date 04/19/19 that the resident has bowel and bladder incontinence, with a goal that the resident will not experience impaired skin integrity due to incontinence and the resident will remain free of urinary tract infection for ninety (90) days with a target date documented 07/18/19. Continued review revealed approaches, which included to provide frequent skin care, keep the resident clean and dry, and check and change the resident every two (2) to three (3) hours or per individual program. There was no documented evidence of a plan of care to address the resident's use of a urinary catheter and no documented evidence the plan of care addressed bladder retraining. Review of the physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Continued review of the order revealed to Clamp the F/C (Foley catheter) for two (2) hours then unclamp for one (1) hour for twenty-four (24) hours; then on day two (2), clamp the catheter for four (4) hours and unclamp for one (1) hour for twenty-four (24) hours; then day three (3), to clamp the catheter for eight (8) hours and unclamp for one (1) hour, then to discontinue the urinary catheter. However, review of the clinical record for Resident #77 revealed no documented evidence the Physician orders, dated 06/07/19, to start bladder retraining were implemented. Observation of Resident #77, on 06/26/19 at 9:50 AM and 06/27/19 at 10:35 AM, revealed the resident was observed with a urinary catheter bag to bedside drainage, with yellow urine observed in the tubing. Interview with the Director of Nursing (DON), on 06/27/19 at 5:50 PM, revealed she reviewed Resident #77's record and stated she cannot find anything in the record as to whether the physician orders, dated 06/07/19, for bladder retraining and discontinuing the urinary catheter was done or not done; but stated the resident obviously still has the catheter. Continued interview with the DON revealed she reviewed Resident #77's plan of care and indicated there was nothing in the care plan regarding the bladder retraining or for the urinary catheter. Interview with Licensed Practical Nurse (LPN) #7, on 06/28/19 at 10:58 AM, revealed she was the nurse who documented the Telephone Order, dated 06/07/19, to start bladder retraining for Resident #77. LPN #7 further stated the facility was going through transition with the computer system and she indicated she could not get on the electronic record for the Treatment Administration Record (TAR) so she passed the order along to the next nurse. LPN #7 stated she should have followed up on this and stated she did not. LPN #7 stated she only works on Fridays, Saturdays, and Sundays and when she returned to work, Resident #77 had moved from one unit to another unit when she came back and the order for bladder retraining got lost in this time. LPN #7 stated her DON has educated her on this and said what she should have done was to transfer the order to the Medication Administration Record [REDACTED]. LPN #7 further stated she does not think the bladder retraining for Resident #77 occurred. Continued interview with LPN #7 revealed potential outcomes for continued urinary catheter use could be UTI (Urinary Tract Infection). In addition, LPN #7 stated she thought they update Care Plans from what she understood but she was not familiar with that, and stated she was supposed to get some training on that. LPN #7 stated she did not update anything with Resident #77's care plan because they are on the computer. LPN #7 exited the interview but returned a couple minutes later and reported there is a green binder on the unit with each resident's Care Plan and staff should go there and update the Care Plan and also put updates on the Certified Nurse Aide (CNA) sheet so they would know. LPN #7 stated none of this was done for Resident #77 for the bladder retraining orders. Interview with State Registered Nurse Aide (SRNA) #4, on 06/28/19 at 9:46 AM, revealed she knew what care to provide residents by referring to her CNA guide. In reviewing Resident #77, the CNA guide documented Resident #77 was incontinent of bowel and bladder, large briefs, and there was nothing documented regarding the resident having a catheter. SRNA #4 did say the resident has a catheter and she provided catheter care for the resident when she goes into the room to rotate him every two (2) to three (3) hours. Interview with the MDS Coordinator, on 06/28/19 at 10:35 AM, revealed she took the role as MDS Coordinator on 06/23/19 and the prior MDS Coordinator was no longer employed at the facility. Continued interview revealed the MDS Coordinator explained the process. She indicated a new admission gets a baseline Care Plan and the nurse starts the baseline care plan and then it was reviewed the following day during the IDT (Interdisciplinary Team) meeting and updated. The MDS Coordinator stated after the initial MDS admission assessment the comprehensive care plan was developed, with CAA's, and it would address any [DIAGNOSES REDACTED]. Continued interview revealed the nurses on the floor would often address new issues and place interventions on the Care Plan. The MDS Coordinator further stated the IDT reviews orders in the clinical meeting every morning. She stated she looked at Resident #77's care plan when it was brought to her attention, and she did not find anything addressing urinary catheter care in the resident's care plan. She indicated she would have to find out about the Nurse Aide sheets to see what documentation was on the document. Continued interview with the MDS Coordinator revealed she did not know anything about the bladder retraining order for Resident #77; however, she stated they take the yellow copy of orders to the morning meeting and usually a copy of the orders was provided to MDS coordinator to review. Additional interview with the MDS Coordinator revealed there should have been a plan of care to address the urinary catheter and a care plan regarding the bladder retraining, for Resident #77, and the reason was to ensure the resident did not have complications from the urinary catheter or infections. Interview with the DON, on 06/28/19 at 11:33 AM, revealed she did not find any additional information regarding Resident #77's bladder retraining in the medical record. Further interview with the DON revealed reasons to do the bladder retraining were to remove the catheter and increase independence. Per interview, possible complications for having a urinary catheter if it was not necessary could be a risk of infection. The DON revealed prior to 06/27/19, there was no care plan to address the catheter for Resident #77, and she would expect the care plan to include catheter care and stated the bladder retraining should have been on the care plan as well for Resident #77. The DON stated the facility process was with new orders such as an order for [REDACTED]. Interview with the Administrator, on 06/28/19 at 11:55 AM, revealed there was no evidence the physician's orders [REDACTED].#77 were implemented. Further interview with the Administrator revealed it was her expectation that facility staff would follow physician's orders [REDACTED]. She stated Resident #77 should have had a care plan to address the urinary catheter. Per interview, possible outcome with continuing the urinary catheter use was a risk for infection.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for two (2) of eighteen (18) sampled residents (Residents #3 and #5) The findings include: Interview with the MDS Coordinator, on 06/27/19 at 1:30 PM, revealed the facility did not have a policy related to completing MDS assessments, but the facility followed the RAI guidelines. Review of the RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 06/21/19, revealed five (05) of thirteen (13) MDS records were transmitted late. The facility received warning error message -3749c, care plan completed late, V0200C2 (CAAA care plan signature date) is more than seven (7) day after V0200B2 (CAA process signature date) for Resident #3 and #5. Interview with MDS Coordinator, on 06/27/19 at 1:30 PM, revealed she had been working as MDS at this facility since 05/13/19 and had not received training on MDS for over ten (10) years. Per interview, she used the RAI Manual 3.0 Guidelines to know when to complete and submit MDS Assessments. However, continued interview revealed since working as MDS at the facility she had never submitted MDS assessments. Further, the assessments should have been closed, completed and submitted per the RAI manual. Interview with Director of Nursing, (DON), on 06/27/19 at 4:06 PM, revealed the RAI Guidelines was used to know the timeliness and completion of assessments, and submission timeframes. Per interview, she was unaware that the assessments above were completed or submitted late; however, the Assessments should be completed per the RA I guidelines to ensure accuracy. Continued interview revealed the facility had no audit process in place until (MONTH) to ensure MDS Assessment were completed per RAI Guidelines. Interview with the Administrator, on 06/28/19 at 10:28 AM, revealed she expected the RAI Manual to be followed related to completing and submitting MDS Assessments, for timeliness and accuracy of resident assessments

The facility failed to ensure each resident's assessment was coordinated by and certified as complete by a registered nurse, to the accuracy of the portion of the assessment he or she completed for two (2) ResidentS (Residents #4 and #55). The findings INCLUDE: Review of the facility policy titled Accurate MDS Assessment, implemented date 03/10/19, revealed the facility would ensure all participates in the assessment process have the requisite knowledge to complete an accurate MDS. Further, a Registered Nurse (RN) would conduct or coordinate each assessment with the appropriate participation of health professions and was responsible for certifying that the assessment was completed. Review of CMS's RAI Version 3.0 Manual, chapter 5: Submission and Correction of the MDS Assessment revealed for an Admission assessment the MDS Completion date (Z0500B) must be no lo later than thirteen (13) days after the Entry Date (A1600). Further, all non-admission OBRA and PPS assessments and other comprehensive MDS assessments, the MDS Completion date (Z0500B) must be no later than fourteen (14) day after the the Assessment Reference Date (A2300). 1. Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 06/21/19 revealed a warning error message -3749a, Annual Assessment completed late, Z0500B was more than fourteen (14) day after A2300 (Assessment reference date) for Resident #55. 2. Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 06/27/19, revealed a warning error message -3810d, record submitted late, more than fourteen (14) days after Z0500B on this new (A0050 equal 1) Quarterly Assessment, for Resident #4. Interview with MDS Coordinator, on 06/27/19 at 1:30 PM, revealed she had been working as MDS at this facility since 05/13/19 and had not received training on MDS for over ten (10) years. Per interview, she used the RAI Manual 3.0 Guidelines to know when to complete and MDS Assessments. Further, the assessments should have been certified/completed by a RN after completion of the Assessment. Interview with Director of Nursing (DON), on 06/27/19 at 4:06 PM revealed the MDS Coordinator, RN used the RAI Guidelines to know the timeliness and completion of assessments. Per interview, she was unaware that the assessments above were completed late; however, the Assessments should be completed per the RA I guidelines to ensure accuracy. Continued interview revealed the facility had no audit process in place until (MONTH) to ensure MDS Assessments were completed per RAI Guidelines. Interview with the Administrator, on 06/28/19 at 10:28 AM revealed she expected the RAI Manual to be followed related to certifying and completing MDS Assessments, timely and accurately of resident assessments

Based on interview, record review and review of the facility's policy, it was determined the facility failed to provide routine and emergency drugs and biologicals and failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for one (1) of eighteen (18) sampled residents (Resident #49). Per interview on 06/25/19, with the Resident and the resident's representative, Ranitine ([MEDICATION NAME]) medication was ordered by an out of facility provider and given to the facility's nursing staff on 06/17/19. Record review of Resident #49's physician's orders revealed no documented evidence of an order on 06/17/19 for [MEDICATION NAME]. However, investigation revealed the [MEDICATION NAME] had been prescribed for Resident #49 on 06/17/19 but was not made available to the resident until 06/26/19. Additionally, facility nursing staff interviews revealed the order for [MEDICATION NAME] was sent to the pharmacy on 06/17/19, was not received, and follow up was made to the pharmacy on two (2) separate days attempting to get the medication to the facility. However, the medication was not received by the facility until 06/26/19. The findings Include: Review of the facility policy titled Green Meadows Physician's Orders, date implemented 03/01/19, revealed medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. Continued review of the Green Meadows Physician's Orders policy revealed Documentation of Medication Orders, which noted each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record [REDACTED]. Enter the order on the medication order and receipt record. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR indicated [REDACTED]. Further review of the Green Meadows Physician's Orders policy revealed Handwritten Order Signed by the Physician section of the policy which documented the charge nurse on duty at the time the order is received should note the order and enter it on the physician's order sheet, if not written by the physician. If necessary, the order should be clarified before the physician leaves the nursing station whenever possible. Continued review of the policy revealed Verbal Orders section, which documented the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Physician orders should be signed per state specific guidelines. Per the policy, the section titled Written Transfer Orders (sent with a resident by a hospital or other health care facility), documented implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending, before medications are administered. The nurse should document verification on the admission order record by entering the time, date, and signature. Record review revealed the facility admitted Resident #49 to the facility on [DATE]. Per the medical record, Resident #49 had [DIAGNOSES REDACTED]. Review of the most recent MDS Assessment, a Quarterly assessment dated [DATE], revealed Resident #49 was assessed by the facility as having a BIMS (Brief Interview for Mental Status) score of fifteen (15) out of fifteen (15). Continued review of the assessment revealed the resident received a therapeutic diet. Review of the Comprehensive Care Plan for Resident #49 revealed a plan of care/problem dated 03/23/18 for potential for weight loss related to being on a therapeutic diet, DM (Diabetes Mellitus), decreased mobility with left sided weakness,[REDACATED], food allergies [REDACTED]. Per the care plan, approaches included weigh and record as ordered or as deemed appropriate; offer HS (bedtime) snack; and an approach dated 06/18/19 to administer medications for GERD/DM ([MEDICAL CONDITION] Reflux Disease/Diabetes Mellitus) as ordered. Interview with Resident #49 and the resident's Representative on 06/25/19 at 3:50 PM revealed the resident representative took the resident to an outside physician appointment for the resident's stomach on 06/17/19. The resident was given a prescription for [MEDICATION NAME] ([MEDICATION NAME]) and the resident representative stated he/she brought it back to the facility and was advised by facility staff they would have the medication in a couple days; however, the representative stated he/she had asked about 4 times since they returned with the prescription on 06/17/19, and the resident still had not received the medication. The resident Representative stated she had asked a facility nurse about the medication on the date of interview, 06/25/19, and was told by the nurse, she had to call the doctor to verify the time the medication would be administered. Review of the Physician's Orders dated June, 2019, revealed a telephone order dated 06/25/19 to discontinue current [MEDICATION NAME] order and restart [MEDICATION NAME] 150 mg (milligrams) PO BID (by mouth two times a day). Continued review of the telephone orders revealed an order dated 06/26/19 for [MEDICATION NAME] 150 mg one PO (by mouth) now (one time only) for GI (gastrointestinal). Review of the Treatment Assessment Report Nurse's Note dated 06/26/19 revealed a note which documented late entry on 06/25/19, which documented the Physician was contacted related to previous [MEDICATION NAME] order. New order obtained to discontinue order from 06/17/19 and administer [MEDICATION NAME] BID (twice a day) at 6:00 AM and HS (hour of sleep). The documentation further stated the daughter was in the facility and aware. Continued review of the Nurse's Notes revealed a note dated 06/26/19 which documented physician contacted, new order obtained for [MEDICATION NAME] 150 mg PO (by mouth) Now (one time only). Although requested, the facility did not provide a written documentation of the prescription for [MEDICATION NAME] for Resident #49, that was originally prescribed on 06/17/19. Interview on 06/26/19 at 1:18 PM with the Director of Nursing (DON) revealed Resident #49's prescription for [MEDICATION NAME] that came from the outside physician office on 06/17/19, should have been faxed to pharmacy; however, the pharmacy said they didn't receive it. Continued interview with the DON revealed the facility physician was notified on 06/25/19 that the medication didn't get started on the 06/17/19, and obtain orders. The DON further stated the order for [MEDICATION NAME] from 06/17/19 was discontinued and new order for [MEDICATION NAME] was obtained, and the medication arrived today (06/26/19). The DON further stated Resident #49 received a now dose on 06/26/19 and stated the [MEDICATION NAME] was in the medication cart. The DON stated she was notified by a nurse about the [MEDICATION NAME] on 06/25/19, and she was not sure why the medication wasn't ordered on [DATE]. Further interview with the DON revealed it was not acceptable for Resident #49 to have to wait from 06/17/19 to 06/26/19 to receive the ordered [MEDICATION NAME]. Per interview, possible outcomes could be the resident could have stomach issues. Interview on 06/26/19 at 3:52 PM with Licensed Practical Nurse (LPN) #6 revealed she thought LPN #7 read the orders to her on 06/17/19 for Resident #49's new prescription for [MEDICATION NAME] on that date, 06/17/19, and LPN #6 indicated she told LPN #7 she would put it on the MAR. LPN #6 stated LPN #7 told her she would do the rest; and LPN #6 stated she did not know if the order for [MEDICATION NAME] was sent to pharmacy or not. Telephone interview with LPN #7 on 06/27/19 at 4:15 PM revealed Resident #49 went for an appointment with outside family doctor and dentist on 06/17/19 and the resident returned with a prescription for [MEDICATION NAME] ([MEDICATION NAME]). LPN #7 indicated she had to write the order for it because it was an outside provider, and stated she did write the order, but didn't contact the resident's physician. She indicated she didn't call the resident's facility physician. Continued interview revealed she faxed the order and script to the pharmacy. LPN #7 stated she wrote the order because Resident #49 didn't have any empty orders and the LPN stated she wrote it on a brand new Physician order sheet, on the top, and faxed to the pharmacy. LPN #7 indicated conformation usually just came out on the bottom of the document and they put that in a basket next to the fax machine; however, LPN #7 said this couldn't be located. LPN #7 indicated she put the outside physician's name on the order, but should have contacted the physician at the facility. LPN #7 stated she followed up with pharmacy twice on the [MEDICATION NAME] for Resident #49, on 06/22/19 and 06/23/19; however, she stated she did not document this. Interview on 06/27/19 at 4:55 PM with the pharmacy's Regional Director of Customer Success, revealed the pharmacy received a faxed order for Resident #49's [MEDICATION NAME] on 6/25/19 at 2:25 PM, and the pharmacy delivery ticket indicated the medication was delivered to the facility on [DATE] at 2:17 AM. Continued interview with the Regional Director revealed he would check to see if the pharmacy received calls from facility staff regarding the medication. The Regional Director stated he did not have any dispense for [MEDICATION NAME] for Resident #49 on for 06/17/19. Per interview, [MEDICATION NAME] typically was used for heartburn and acid reflux and potential outcome of a resident not having the medication could be discomfort, persistent heartburn or acid reflux. Subsequent information received via email from the pharmacy's Regional Director of Customer Success on 06/28/2019 at 2:06 PM revealed the following: Communication was initiated by the pharmacy on 06/18/19, requesting that an order be sent via the facility electronic health record software. The Regional Director indicated the facility did not use electronic software and would not have been able to send an order electronically. The Regional Director indicated a hospital order was sent, but the pharmacy could not accept those as valid orders; and indicated the pharmacy needed an order, written on a telephone order form, faxed from the facility to the pharmacy. The Regional Director further indicated once the pharmacy received the telephone order form, the medication was dispensed. The Regional Director stated there was communication between the facility and the pharmacy. He further documented the pharmacy customer service would have directed the nurse to fax an order, opposed to using the electronic health record (which the facility does not use), then the medication ([MEDICATION NAME] for Resident #49) would have been received much sooner. He further indicated the pharmacy had escalated this incident to their QA department. On 06/28/19 at 11:43 AMn interview with the facility DON revealed [MEDICATION NAME] was ordered on [DATE] for Resident #49 and the medication was not received by the facility until 06/26/19. The DON stated this was not an acceptable amount of time, and that it was her expectation that facility policy and procedures be followed regarding obtaining medication for residents. The DON indicated a possible outcome for the resident was upset stomach. The DON further indicated the facility audited physician's orders and observed medication carts to ensure medications were in the cart; however, she indicated the facility had no physician's telephone order to alert that there was a new medication, [MEDICATION NAME], for Resident #49. Interview on 06/28/19 at 11:47 AM with the facility Administrator revealed Resident #49 waiting from 06/17/19, when the [MEDICATION NAME] was ordered by an outside physician, to 6/26/19 to receive the medication at the facility was not an acceptable amount of time. Continued interview with the Administrator revealed the resident not having the prescribed stomach medication could possibly cause upset stomach. Per interview it was her expectation that facility policy and procedures be followed regarding obtaining medication for residents, and that the facility follow physician orders.

Based on observation, interview, record review and review of facility's Policy, it was determined the facility failed to ensure that a resident who enters the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; was assessed for removal of the catheter as soon as possible; and received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (1) of eighteen (18) sampled residents (Resident #77). Review of Resident #77's physicians orders, revealed a physician's orders [REDACTED]. However, there was no documented evidence the bladder retraining occurred or the urinary catheter was discontinued. Further, observations and interviews revealed the resident continued to have a urinary catheter throughout the survey. The Findings Include: Review of the facility's Policy titled physician's orders [REDACTED]. Continued review of the policy revealed the nurse should document an order by telephone or in person on the physician's orders [REDACTED]. Review of the facility's Policy titled Catheter Care Policy, date implemented 03/01/19, revealed it is the policy of the facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Record review revealed the facility admitted Resident #77 to the facility on [DATE]. Resident #77 had diagnoses, which included Dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Continued review of the record revealed the facility assessed Resident #77 per the most recent MDS assessment, and annual assessment, dated 04/16/19, as having a Brief Interview Mental Status (BIMS) score of thirteen (13) of fifteen (15), the resident was assessed as always incontinent of urine and bowel, and was not assessed as having a catheter at the time of the assessment. Record review revealed a Comprehensive Care Plan for Resident #77 with a problem onset date 04/19/19 that resident has bowel and bladder incontinence, with a goal that the resident will not experience impaired skin integrity due to incontinence and the resident will remain free of urinary tract infection for ninety (90) days with a target date documented 07/18/19. Continued review revealed approaches included to provide frequent skin care, keep the resident clean and dry, and check and change the resident every two (2) to three (3) hours or per individual program. There was no documented evidence of a plan of care to address the resident's use of a urinary catheter and no evidence the plan of care addressed bladder retraining. Review of the physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Continued review of the order revealed to Clamp the F/C (Foley catheter) for two (2) hours then unclamp for one (1) hour for twenty-four (24) hours; then on day two (2), clamp the catheter for four (4) hours and unclamp for one (1) hour for twenty-four (24) hours; then day three (3), to clamp the catheter for eight (8) hours and unclamp for one (1) hour, then to discontinue the urinary catheter. However, review of the clinical record for Resident #77 revealed no documented evidence the Physician orders, dated 06/07/19, to start bladder retraining were implemented. Observation of Resident #77, on 06/26/19 at 9:50 AM and 06/27/19 at 10:35 AM, revealed the resident was observed with a urinary catheter bag to bedside drainage, with yellow urine observed in the tubing. Interview with the DON, on 06/27/19 at 5:50 PM, revealed she reviewed Resident #77's record and stated she cannot find anything in the record as to whether the physician order, dated 6/7/19, for bladder retraining and discontinuing the catheter was done or not done; but stated the resident obviously still has the catheter. Continued interview with the DON revealed she reviewed Resident #77's plan of care and indicated there was nothing in the care plan regarding the bladder retraining or for the urinary catheter. Interview with Licensed Practical Nurse (LPN) #8, on 06/28/19 at 10:05 AM, revealed she had only worked with Resident #77 for about three (3) days, and stated the resident was on another unit when the bladder retraining was ordered. Interview with LPN #7, on 06/28/19 at 10:58 AM, revealed the resident's family thought the catheter was causing Urinary Tract Infections and this was the reason for the bladder retraining order. LPN #7 further stated the reason Resident #77 had the urinary catheter to begin with was for [MEDICAL CONDITION]. Continued interview with LPN #7 revealed the facility was going through transition with the computer and she indicated she could not get on the electronic record for the Treatment Administration Record (TAR) so she passed the order along to the next nurse. LPN #7 stated she should have followed up on this; however, she did not. LPN #7 stated she only works on Fridays, Saturdays, and Sundays and when she returned to work, Resident #77 had moved from one unit to another unit. She stated when she came back to work, the order for bladder retraining got lost. LPN #7 stated her DON has educated her on this and said what she should have done was to transfer the order to the Medication Administration Record [REDACTED]. LPN #7 further stated she does not think the bladder retraining for Resident #77 occurred. Continued interview with LPN #7 revealed potential outcomes for continued catheter use could be UTI (Urinary Tract Infection). In addition, LPN #7 stated she thought they update Care Plans from what she understood but she was not familiar with that, and stated she was supposed to get some training on that. LPN #7 stated she did not update anything with Resident #77's care plan because they are on the computer. LPN #7 exited the interview but returned a couple minutes later and reported there is a green binder on the unit with each resident's Care Plan and staff should go there and update the Care Plan and also put updates on the Certified Nurse Aid (CAN) sheet so they would know. LPN #7 stated none of this was done for Resident #77 for the bladder retraining orders. Interview with the MDS Coordinator, on 06/28/19 at 10:35 AM, revealed she took the role as MDS Coordinator on 06/23/19 and the prior MDS Coordinator was no longer employed at the facility. Continued interview revealed the MDS Coordinator explained the process. She indicated a new admission gets a baseline Care Plan and the nurse starts the baseline care plan and then it was reviewed the following day during the IDT (Interdisciplinary Team) meeting and updated. The MDS Coordinator stated after the initial MDS admission assessment, the comprehensive care plan was developed, with CAA's, and it would address any [DIAGNOSES REDACTED]. Continued interview revealed the nurses on the floor would often address new issues and place interventions on the Care Plan. The MDS Coordinator further stated the IDT reviews orders in the clinical meeting every morning. She stated she looked at Resident #77's care plan when it was brought to her attention, she did not find anything addressing catheter care in the resident's care plan. She indicated she would have to find out about the nurse aid sheets to see what documentation was on the document. Continued interview with the MDS Coordinator revealed she did not know anything about the bladder retraining order for Resident #77; however, she stated they take the yellow copy of orders to the morning meeting and usually a copy of the orders was provided to MDS coordinator to review. Continued interview with the MDS Coordinator revealed Resident #77 should have had a plan of care to address the catheter and a care plan regarding the bladder retraining, and the reason was to ensure the resident did not have complications from the catheter or infections. Interview with the DON, on 06/28/19 at 11:33 AM, revealed she did not find any additional information regarding Resident #77's bladder retraining in the medical record. Further interview with the DON revealed reasons to do the bladder retraining were to remove the catheter and increase independence. Per interview, possible complications for having a catheter if it were not necessary could be risk of infection. Additional interview with the DON revealed prior to 06/27/19, there was no care plan to address the catheter for Resident #77, and she would expect the care plan to include catheter care and stated the bladder retraining should have been on the care plan as well for Resident #77. The DON stated the facility process was with new orders such as the order for a catheter or bladder retraining, the information would go on the resident care plan, CNA care guide, and would be documented on the TAR as a treatment. The DON stated it was her expectation that staff follow this process and the facility policies and procedures. Interview with the Administrator, on 06/28/19 at 11:55 AM, revealed there was no evidence the physician's orders [REDACTED].#77 were carried out. Further interview with the Administrator revealed it was her expectation that facility staff would follow physician's orders [REDACTED]. She stated Resident #77 should have had a care plan to address the catheter. Per interview, possible outcome with continuing the urinary catheter use was risk for infection.

Based on observation, interview, record review and review of facility policy it was determined the facility failed to provide services to meet professional standards of quality for one (1) of eighteen (18) sampled residents (Resident #47). Review of Resident #47's Treatment Administration Record (TAR), for (MONTH) 2019, revealed no documented evidence of the treatment for [REDACTED]. The Findings Include: Review of the facility policy titled Green(NAME)Physician's Orders, date implemented 03/01/19, revealed verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician,on the next visit to the facility. Continued review of the policy revealed the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Continued review of the Green(NAME)Physician's Orders policy revealed Documentation of Medication Orders, which noted each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record [REDACTED]. Enter the order on the medication order and receipt record. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR indicated [REDACTED]. Record review of the clinical record revealed the facility admitted Resident #47 to the facility from an acute hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 04/24/19 revealed the facility assessed Resident #47 as having a BIMS (Brief Interview Mental Status) score of twelve (12) of fifteen (15). Continued review of the MDS assessment revealed the facility assessed Resident #47 as at risk of developing pressure ulcers/injuries, had two (2) stage two (2) pressure ulcers present on admission, and was documented as having skin tears. Review of the CAA's (Care Area Assessment Summary) revealed Resident # 47 was recently hospitalized due to a fall with injury and weakness, and was found to have a UTI (urinary tract infection). Continued review revealed the resident has multiple [DIAGNOSES REDACTED]. Review revealed the resident was admitted with two stage two pressure injuries and a venous stasis ulcer and these put the resident at risk for additional complications such as additional skin injuries, and care plan will be developed. Review of the Physicians Telephone Orders for Resident #47 revealed an order dated 06/21/19 to cleanse right upper arm with NS (normal saline), cover with non stick dressing BID (two times a day) until healed. Review of the Nurse's Notes for Resident #47 revealed a note dated 06/21/19 at 1:20 PM, which documented the physician was at the facility and saw the resident and new order to cleanse right upper arm skin tear with NS (normal saline) apply [MEDICATION NAME], non adherent pad and border guaze every shift until healed. Review of the TAR (Treatment Administration Record) for (MONTH) 2019 for Resident #47 revealed no documented evidence of a treatment in place for Resident #47's right upper arm/extremity. Review of the Comprehensive Care Plan for Resident #47 revealed a plan of care with the problem Fragile skin (high risk for skin tears/bruising with on-set date on 04/30/19 and goal that the resident will be free from new bruises times ninety (90) days with target date 07/29/19; a goal the resident will be free from skin tears times ninety (90) days with a target date of 07/29/19; and a goal skin tear to left upper extremity will heal without complications with a begin date of 06/13/19 and a target date of 07/13/19. Further review of the plan of care revealed approaches which included treatment to skin tear to LUE (left upper extremity) as ordered, observe for signs and symptoms of infection, and notify physician as needed. There was no documented evidence of a plan of care or approaches to address the skin tear to the resident's right upper extremity. Interview with Licensed Practical Nurse (LPN) #8 on 06/27/19 at 10:12 AM revealed Resident #47 had skin tears to both arms, had paper thin skin, and they cleaned then use petroleum then wrap them. She stated she didn't htink there was anything on the TAR about this treatment. Interview with Registered Nurse (RN) #5/Wound Nurse on 06/27/19 at 10:14 AM revealed she only did documentation on pressure ulcers. Continued interview revealed she didn't do wound documentation on skin tears, and treatments were done by the nurses on the unit. She further stated any treatment should be documented on the TAR. Interview with the Director of Nursing (DON) on 06/27/19 at 05:48 PM revealed she did not find any documented treatment to the skin tear to the right upper extremity on Resident #47's TAR and did not find anything documented on Residednt #47's Care Plan to address the skin tear to the right upper extremity. The DON stated any physician's ordered treatment should be record on the TAR. Subsequent interview with LPN #8 on 06/28/19 at 10:18 AM to inquire about the documentation regarding the skin tear to Resident #47's right upper arm, the physician's order, and the Nurse's Note, dated 06/21/19, revealed she did not recall what the order was for Resident #47's right upper extremity, but that is sould be on the TAR. Interview with the MDS Coordinator on 06/28/19 at 10:35 AM revealed she took the role as MDS Coordinator on 06/23/19 and the prior MDS Coordinator was no longer employed at the facility. Interview with the Director of Nursing (DON), on 06/28/19 at 11:39 AM revealed she was unable to locate any documentation prior to 06/27/19 with regards to Resident #47's RUE skin tear. Per interview, the DON indicated she would expect the physician treatment order to be on the resident's TAR and Care Plan. Further interview revealed it was her expectation that nurses follow facility Policy and Procedures from obtaining the physician's order, to documenting on the TAR, and updating the plan of care for the resident. Interview with the Administrator on 06/28/19 at 11:51 AM revealed she had been made aware Resident #47 had a treatment order for the RUE with no evidence the treatment was documented on the TAR and no evidence the plan of care was revised. Continued interview with the Administrator revealed a resident with a change of condition should have treatments documented on the TAR and the care plan should be updated. Per interview, a possible outcome could be failure to follow the plan of care; and if the treatment was not documented on the TAR, there could be failure to ensure the order was carried out. The Administrator further stated it was her expectation that staff follow physician's orders, update MAR's (Medication Administration Record), TAR's and Care Plans according to physician's orders.

Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of eighteen (18) sampled residents (Resident #47). Resident #47 had a skin tear to the right upper arm and review of Resident #47's Comprehensive Plan of Care revealed no documented evidence the Care Plan was revised to include the skin tear to the right upper arm. The findings include: Review of the facility policy Care Plan Revisions Upon Status Change, date implemented 03/01/19, revealed the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Per the policy, the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Continued review of the Care Plan Revisions Upon Status Change, revealed upon identification of a change in status, the nurse will notify the MDS coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care Plan will be modified as needed by the MDS Coordinator or other designated staff member. Continued review of the policy Care Plan Revisions Upon Status Change, revealed the Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in then resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. The MDS Coordinator will determine whether a Significant change in status Assessment is warranted and if so, the assessment will be completed according to established procedures. Review of the facility policy titled Green(NAME)Physician's Orders, date implemented 03/01/19, revealed verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility. Continued review of the policy revealed the nurse should document an order by telephone or in person on the physician's order sheet, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical record. Continued review of the Green(NAME)Physician's Orders policy revealed Documentation of Medication Orders, which noted each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record [REDACTED]. Enter the order on the medication order and receipt record. Call or fax the medication order to the provider pharmacy. Transcribe newly prescribed medications on the MAR indicated [REDACTED]. Review of the clinical record revealed the facility admitted Resident #47 to the facility from an acute hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 04/24/19 revealed the facility assessed Resident #47 as having a BIMS (Brief Interview Mental Status) score of twelve (12) of fifteen (15). Continued review of the MDS assessment revealed the facility assessed Resident #47 as at risk of developing pressure ulcers/injuries, had two (2) stage two (2) pressure ulcers present on admission, and was documented as having skin tears. Review of the CAA's (Care Area Assessment Summary) revealed Resident # 47 has multiple [DIAGNOSES REDACTED]. Review revealed the resident was admitted with two stage two pressure injuries and a venous stasis ulcer and these put the resident at risk for additional complications such as additional skin injuries, and care plan will be developed. Review of the Physicians Telephone Orders for Resident #47 revealed an order dated 06/21/19 to cleanse right upper arm with NS (normal saline), cover with non stick dressing BID (two times a day) until healed. Review of the Nurse's Notes for Resident #47 revealed a note dated 06/21/19 at 1:20 PM, which documented the physician was at the facility and saw the resident and new order to cleanse right upper arm skin tear with NS (normal saline) apply [MEDICATION NAME], non adherent pad and border gauze every shift until healed. Review of the TAR (Treatment Administration Record) for Resident #47 revealed no evidence of a treatment in place for Resident #47's right upper arm/extremity. Review of Resident #47's Comprehensive Care Plan revealed a plan of care with the problem Fragile skin (high risk for skin tears/bruising with on-set date on 04/30/19 and goal that the resident will be free from new bruises times ninety (90) days with target date 07/29/19; a goal the resident will be free from skin tears times ninety (90) days with a target date of 07/29/19; and a goal skin tear to left upper extremity will heal without complications with a begin date of 06/13/19 and a target date of 07/13/19. Further review of the plan of care revealed approaches which included treatment to skin tear to LUE (left upper extremity) as ordered, observe for signs and symptoms of infection, and notify physician as needed. Record review revealed there was no documented evidence the care plan was revised to indicate Resident #47 encounted a skin tear on 06/21/19 and no documented evidence of interventions to address the skin tear to the resident's right upper extremity. Interview with Licensed Practical Nurse (LPN) #8 on 06/27/19 at 10:12 AM revealed Resident #47 has skin tears to both arms, has paper thin skin, and they clean and used petroleum then wrap them. She reported the resident did not have any pressure ulcers, the care plan should be revised to include the skin tear. Interview on 06/27/19 at 05:48 PM with the Director of Nursing (DON) revealed she did not find any documented treatment to the skin tear to the right upper extremity on Resident #47's TAR and did not find anything documented on Resident #47's Care Plan to address the skin tear to the right upper extremity. Interview with the MDS Coordinator on 06/28/19 at 10:35 AM revealed she took the role as MDS Coordinator on 06/23/19. Per interview, the prior MDS Coordinator was no longer employed at the facility. Continued interview revealed the facility process for a newly admitted resident was for the nurse to start the baseline care plan and then it was reviewed the following day during the IDT (Interdisciplinary Team) meeting and updated. The MDS Coordinator stated after the initial MDS admission assessment the comprehensive care plan was developed, with CAA's, and also it would address any [DIAGNOSES REDACTED]. The MDS Coordinator further stated the IDT reviews orders in clinical meeting every morning. Per interview, Resident #47 had fragile skin and the resident's plan of care should have been revised to include the treatment/interventions for the right upper extremity (RUE) skin tear. During an interview with the DON on 06/28/19 at 11:39 AM, the DON stated she wasn't able to locate any documentation prior to yesterday with regards to Resident #47's RUE skin tear. Per interview, the DON indicated she would expect the physician treatment order to be on the resident's Treatment Administration Record (TAR) and Care Plan. Further interview revealed it was her expectation that nurses follow facility Policy and Procedures from obtaining the physician's order, to documenting on the TAR, and updating the plan of care for the resident. The DON stated if a resident has a change of condition, new orders should be transcribed and carried out, and followed through to the care plan. Interview with the Administrator on 06/28/19 at 11:51 AM revealed she had been made aware Resident #47 had a treatment order for the RUE with no evidence the treatment was documented on the TAR and no evidence the plan of care was revised. Continued interview with the Administrator revealed a resident with a change of condition should have treatments documented on the TAR and the care plan should be updated. Per interview, a possible outcome could be failure to follow the plan of care; and if the treatment is not documented on the TAR, there could be failure to ensure the order was carried out. The Administrator further stated it was her expectation that staff follow physician's orders, update MAR's (Medication Administration Record), TAR's and Care Plans according to the resident's plan of care.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed no less than every three (3) months for one (1) of eighteen (18) sampled residents (Resident #5). Review of Resident #5's medical record revealed the facility completed the resident's Quarterly MDS assessment on 01/14/19; however, the facility failed to open a quarterly assessment until 06/25/19 (date of the survey), approximately five (5) months later. The findings include: Interview with the MDS Coordinator on 06/27/19 at 1:30 PM, revealed the facility did not have a policy related to completing MDS assessments, but the facility followed the Resident Assessment Instrument (RAI) guidelines. Review of the RAI 3.0 User's Manual revealed a quarterly assessment must be completed at least every ninety-two (92) days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Review of Resident #5's medical record revealed the facility admitted the resident on 10/31/18 with [DIAGNOSES REDACTED]. Continued Review of Resident #5's medical record revealed the facility completed an Admission MDS assessment dated [DATE]. Further review of the medical record revealed the next assessment the facility completed of Resident #5 was a Quarterly MDS assessment on 01/14/19. There was no documented evidence that the facility completed another assessment for the resident within 92 days of the 01/14/19 assessment. Interview with the MDS Coordinator, on 06/27/19 at 1:30 PM, revealed she had been working as the MDS Coordinator since 05/03/19 and had not received training on MDS for over ten (10) years. Additionally, she was responsible for completing the MDS assessments. Per interview, she used the RAI Manual Guidelines to know when an assessment was due to be completed. Further, she did not know why the Quarterly assessment was missed for Resident #5. Interview with the Director of Nursing (DON), on 06/27/19 at 4:06 PM, revealed the MDS Coordinator was responsible for completing resident MDS assessments. Per interview, she was unaware that the assessment for Resident #5 was not completed after the 01/14/19 Assessments and before the 06/25/19 Assessment. Additionally, the RAI Manual Guidelines was used to know timeliness of assessments. Continued interview revealed the facility had no audit process in place until (MONTH) to ensure MDS Assessment were completed per RAI Guidelines. Further, Resident #5's Quarterly Assessment should have been completed per the RAI Guidelines. Interview with the Administrator, on 06/28/19 at 10:28 AM revealed she expected the RAI Manual to be followed related to completing MDS Assessments, for timeliness and accuracy of resident assessments.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure falls were thoroughly investigated to identify the root cause of the fall and/or implement actions to prevent reoccurrence for two (2) of seven (7) sampled residents, Resident #1 and #7. Record review revealed Resident #7 fell , on 03/27/17, while walking unassisted to the bathroom while wearing slippers instead of non-skid footwear. The resident sustained [REDACTED]. Record review revealed the facility identified the resident was not wearing non-skid footwear at the time of the fall; however, there was no documented evidence staff was educated on the use of non-skid footwear. On 05/08/17, Resident #7 had a second fall while ambulating in the room and sustained a skin tear to the right arm. The resident was not wearing non-skid socks at the time of this fall; however, the facility failed to identify a trend related to this intervention not being implemented. Record review revealed Resident #1 fell on [DATE] with no injuries. The facility identified the resident was not wearing non-skid socks per the plan of care and the resident's sensor alarm was noted to malfunction. No other interventions were determined to be needed for the resident after the fall. On 04/20/17, Resident #1 sustained a second fall. Resident #1 was found on the floor next to the bed with blood oozing from both nostrils and a hematoma (collection of blood under the skin) to the back of the head. Record review revealed the resident's alarm malfunctioned and the resident was not wearing non-skid socks. However, the facility failed to address the malfunctioning bed alarm or the lack of non-skid footwear. The findings include: Review of the facility policy titled, Fall Prevention, dated March 2017, revealed all residents would be assessed for risk of falls to develop individualized plans of care for each resident. Residents at risk would have safety devices initiated as appropriate to the bed, wheelchair, chair, and room. Residents would be reviewed on an individual basis to determine which, if any, devices were appropriate. A completed Fall Risk Assessment would be reviewed by the interdisciplinary team for all residents with increased risk of falls. The fall risk approaches would be included in the plan of care for implementation. The Falls Committee would review all resident falls, medical records, care plan and certified nursing assistant assignment sheets to determine the root cause and make recommendations and changes as appropriate. Review of the Secure Safety Solutions manufacturer recommendations, undated, for the bed, chair, and wheelchair alarms, revealed the devices must be tested before each use with a resident to make sure they functioned properly. The recommendations also stated the facility should use caution because the products were not considered a restraint, therefore would not prevent a resident from getting out of the bed or chair. The products were designed as a monitor, alerting the caregiver when the resident had risen from their bed or chair. In addition, the products were not a replacement for routine visual monitoring and were to be used in conjunction with a total fall prevention program. Review of resident Set-up and Use when using the chair and bed sensor pad, revealed staff should place the pad under the buttocks of the resident and turn the unit on using the on/off switch. Have the resident attempt to stand to remove pressure from the sensor pad. The alarm would sound. To silence the alarm, turn the alarm off or place the patient back on the sensor pad. Place the monitor out of reach of the patient. If alarm fails to sound, immediately discontinue use. Most false alarms were do to the result of poor pad placement or low batteries. Always test the monitor and sensor pad before each use. 1. Review of Resident #7's clinical record, on 05/23/17, revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 01/24/17, revealed the resident was not interviewable. Review of Resident #7's comprehensive plan of care, developed on 12/05/16, revealed the resident was at risk for falls related to impaired balance and advancing age. The goal was for the resident to remain free of injuries related to falls. The approaches stated the staff was to provide verbal reminders not to ambulate or transfer without assistance; as able to understand. Staff was to ensure the resident wore properly fitting non-skid foot wear for ambulation and/or transfers. Review of Nursing Documentation, dated 03/27/17, revealed Resident #7 fell trying to use the bathroom. The resident hit the back of his/her head on the bathroom door and sustained a fractured left hip. Review of the Fall Scene Report, dated 03/27/17, revealed the resident was wearing slippers, lost his/her balance, and slipped at the time of the fall. Continued review of the report revealed the intervention to prevent future falls and to ensure resident safety was for staff to reinforce use of the call light with the resident and use of non-skid socks. The report form stated the root cause of the fall was the resident performed an unsafe transfer. Interview with Certified Nursing Assistant (CNA) #7, on 05/24/17 at 3:45 PM, revealed he was in another resident's room on 03/27/17, when he heard Resident #7's bed alarm sounding. He stated he could not immediately respond to the resident's alarm because he was tending to the other resident. He stated when he finished, he went to Resident #7's room and found him/her on the floor in the bathroom. He stated the resident was assisted back to bed and vitals were taken. CNA #7 stated later in the shift he went to round on the resident and noted a large hematoma (collection of blood under the skin) to the left hip. He stated most residents have non-skid foot wear on the plan of care, but he was not sure if Resident#7 had non-skid foot wear on the their plan of care. Interview with Registered Nurse (RN) #1, on 05/23/17 at 9:05 PM, revealed Resident #7 had walked unassisted to the bathroom to toilet self and fell on [DATE]. She stated Resident #7, hit the back of his/her head on the bathroom door; however, no other injuries were found at the time of the fall. She stated later in the shift she found a hematoma to Resident #7's left hip and called the physician for orders. RN #1 stated X-rays were taken and confirmed a left hip fracture. She stated she completed her portion of the Fall Scene Report and noted the resident was wearing slippers at the time of the fall; instead of the non-skid footwear. She stated it was the responsibility of staff to ensure the resident wore them. However, she did not re-educate staff on the use of them for Resident #7. She stated she determined what appeared to be the root cause of the fall was the resident attempted to ambulate to the bathroom without assistance with loose footwear and one of the slippers came off causing the resident to trip and fall. She stated if staff did not monitor the resident for safety and fall prevention the resident could fall and be injured. Interview with the Patient Care Coordinator (PCC), 05/24/17 at 12:00 PM, revealed she was trained by another staff member to investigate and analyze falls for the root cause. She stated Resident #7 had poor safety awareness and staff was aware he/she would toilet self in between staff assistance with toileting. She stated the root cause of Resident #7's fall on 03/27/17, was the resident performed an unsafe transfer. She stated it was determined the staff had not ensured the resident had on the non-skid footwear. She stated the resident was admitted to the hospital after the fall for surgical repair of the fracture hip and the reassessment for additional care plan interventions was delayed until readmission. However, there was no documented evidence management audited staff for the consistent implementation of fall care plan interventions or re-educated the nursing staff regarding the use of non-skid footwear before or after re-admission. She stated supervision of the staff and the resident was needed to ensure care plan interventions were implemented to prevent unsafe transfers and resident harm. Review of Nursing Documentation, dated 05/08/17, revealed Resident #7 fell and sustained a skin tear to the right arm while trying to remove a wandering resident from his/her room. Review of the Fall Scene Report, dated 05/08/17, revealed the resident was wearing compression stockings at the time of the fall, not non-skid footwear. Interview with CNA #15, on 05/24/17 at 2:20 PM, revealed the nurse responded to the alarm sounding and found Resident #7 on the floor. However, she could not remember if the resident was wearing or required non-skid footwear. Interview with CNA #16, on 05/23/17 at 2:50 PM revealed the nurse responded to the alarm sounding and found the resident on the floor. She stated she did not know if the resident had on non-skid footwear at the time of the fall but most residents used non-skid footwear to protect them from falls. Continued interview with the PCC, 05/24/17 at 12:00 PM, revealed on 05/08/17, Resident #7 fell again and sustained a skin tear to the right arm while ambulating in his/her room. Review of the Fall Scene Report, dated 05/08/17, with the PCC, revealed the resident was wearing compression stockings at the time of the fall; without the use of non-skid footwear. The PCC stated the root cause of the fall was the resident performed an unsafe transfer. However, per interview, she had not identified a trend with Resident #7's falls related to not wearing non-skid footwear. She stated the purpose of determining the root cause was to determine if there was a system problem requiring an action plan to ensure harm does not occur to the resident again or to others. She stated the facility did not put an action plan in place regarding the findings determined from Resident #7's two (2) falls. She stated it was part of the process for the management staff to evaluate the contributing factors for trends, implement corrective actions, such as care plan revisions and to monitor for effectiveness; however, that was not done for Resident #7 after either fall. Interview, on 05/25/17 at 10:35 AM, with the Director of Nursing (DON) revealed during the daily morning meeting, resident falls were discussed. She stated Resident #7's falls were discussed; however she had not determined there was a trend with staff not implementing Resident #7's fall care plan interventions. She stated Resident #7 was admitted to the hospital after the 03/27/17 fall for surgical repair of the fractured hip. She stated she believed that was the reason the facility had not followed up with the staff. The DON stated the resident fell again on 05/08/17 and the fall was discussed in the morning meeting; however, she did not direct management staff to re-educate staff regarding Resident #7's care plan interventions for non-skid footwear. She stated she expected staff to implement fall risk interventions such as ensuring Resident #7 had on non-skid foot wear to decrease the chance of falling or sustaining an injury. She stated it was part of the process for the interdisciplinary team in the morning meeting to evaluate the contributing factors for trends, implement corrective actions, then monitor for effectiveness; however that was not done for Resident #7 after either fall. 2. Review of Resident #1's clinical record, on 05/22/17, revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/03/17, revealed the resident was not interviewable. Review of Resident #1's comprehensive plan of care, developed on 05/07/17, revealed the resident was at risk for falls. The goal was for the resident to remain free of injures related to falls. The approaches stated the resident was to wear non-skid socks when not wearing shoes, non-skid strips to the floor and give verbal reminders not to ambulate without assistance as able to understand. The care plan also had an intervention for sensor alarms to the bed and chair with staff to check placement and function every shift and as needed. Review of the Fall Scene Investigation report, dated 04/04/17, revealed Resident #1 experienced an unwitnessed fall from the bed with no injuries. The contributing factors noted at the time of the fall were the resident was disoriented, had on regular socks instead of non-skid socks, and the bed alarm malfunctioned. The report indicated the root cause of the fall was a malfunctioning bed alarm, the resident's mental status, and the resident performing an unsafe transfer. However, no other interventions were determined to be needed for the resident after the fall. Interview with CNA #6, on 05/22/17 at 3:20 PM, revealed Resident #1 fell getting out of the bed, on 04/04/17, and the bed alarm did not sound to alert staff. She stated it was the responsibility of the aides to check the bed/chair alarms for placement and functionality. She stated at times she found bed alarms without batteries and or not turned on, when she did her first rounds on her shift. She stated if alarms were not working properly they were thrown away and a new one was put in its place. Per interview, it was important to have a functioning bed/chair alarm for staff to be alerted so they could prevent a fall or injury. Interview with RN #1, on 05/23/17 at 9:05 PM, revealed Resident #1 had an unwitnessed fall on 04/04/17, due to a malfunctioning bed alarm and the resident was wearing regular socks instead of non-skid footwear. She stated the resident was found on the floor next to the bed with no injuries. She assumed the bed alarm had been checked by the nursing assistant at the beginning of her shift and stated the aides had the responsibility to ensure placement and functioning. At times she checked alarms for functioning because some of the residents would turn them off, but she did not have a formal process for checking for functionality or placement of alarms. She stated she was unable to determine why the alarm had malfunctioned and when a bed alarm malfunctioned the process was to throw it away and replace it with a new one. She further revealed she had not received any additional information regarding checking alarms, monitoring certified nursing assistants implementing bed alarm checks, or education on the bed alarm itself. She stated bed alarms were an important part of the fall prevention plan and if not routinely checked and monitored the device would not alert them to help deter resident falls and harm. Review of the Fall Scene Investigation report, dated 04/20/17, revealed Resident #1 had an unwitnessed fall and the bed alarm malfunctioned. Resident #1 sustained injuries from the fall which included a hematoma (collection of blood under the skin) to the back of the head and bright red blood oozing from both nostrils. The report stated the resident complained of pain in both legs and the right hip after the fall. The contributing factors noted on the report revealed the resident was not wearing non-skid socks at the time of the fall and the bed alarm malfunctioned. The report identified the root cause of the fall was a malfunctioning bed alarm, the resident's inability to comprehend safety issues, and a mental status change with increased restlessness and agitation. There was no identification or documentation of the resident not wearing non-skid socks as part of the root cause nor a trend with the malfunctioning alarm. Interview with CNA #8, on 05/25/17 at 2:15 PM, revealed on 04/20/17 she rounded at the beginning of the shift and checked Resident #1's bed alarm by pressing the button on the alarm box that was connected to the pad under the resident and the box beeped as it usually did. She later found Resident #1 on the floor beside the bed with blood coming out of his/her nose and a knot on the back of the head. She stated the bed alarm did not sound, to alert staff, the resident was trying to get up. She checked the alarm again by pushing the button on the alarm box and it sounded. She stated since the bed alarm system had malfunctioned it was thrown away and a new one was put in place. She revealed the bed alarm pads were disposable but she was not sure how long they could be in use. Per interview, there were times she would find alarms turned off, not in place, and without batteries on her rounds. At times she would find frayed wires that go from the pad to the box that would also cause it to malfunction. She stated she would report her findings to nursing staff but was not sure what nursing did with the information. She stated she did not remember if the resident was wearing non-skid socks, but if the plan of care stated the resident was to have them on, then she was responsible for ensuring they were in place. She had not received coaching or re-education regarding the non-skids socks or the bed alarm after the resident's fall. Interview with CNA #9, on 05/24/17 at 2:20 PM, revealed at times she would find bed/chair alarms turned off, with frayed wires, and without batteries. However, she believed it was staff not replacing batteries versus the residents taking the batteries out. She stated she had not received additional education related to the monitoring for malfunctioning alarms. She stated if alarms were not functioning properly a resident could get up without staff knowledge, fall and get injured. Interview with CNA #7, on 05/24/17 at 3:45 PM, revealed he had found bed/alarms turned off and without batteries. He stated it was the responsibility of the aides to ensure the alarms were in place and functioning. He had not received additional education regarding monitoring for malfunctioning alarms after Resident #1's fall. He stated it was important for resident safety to ensure bed/chair alarms were in place and functioning properly. Interview with RN #1, on 05/23/17 at 9:05 PM, revealed Resident #1 had fallen out of bed on 04/20/17 and was found with a hematoma to the back of the head and blood oozing from the nose. She stated the resident's bed alarm did not sound to alert staff and the resident did not have on non-skid footwear at the time of the fall. RN #1 stated she did not determine what caused the alarm to malfunction, she just threw it away, and replaced it with a new one. She revealed after the fall she was not given any additional direction or training regarding the alarms. Per interview, she did not remember if she coached the aide regarding the non-skid footwear. She stated it was a safety hazard for the resident not to wear non-skid footwear and to have malfunctioning bed alarms. Interview with the PCC, 05/24/17 at 12:00 PM, revealed Resident #1 had poor safety awareness. She stated on 04/04/17 Resident #1 was confused and got up out of bed and fell , and the root cause of Resident #1's fall was the resident performed an unsafe transfer. It was determined the staff had not ensured the resident had on non-skid footwear, per the plan of care, and the bed alarm malfunctioned. She stated she did not investigate Resident #1's fall; however it was discussed in the morning meeting. The team reviewed the Fall Scene Investigation Report and no other interventions were determined to be needed for the resident after the fall. She stated because the bed alarm was replaced no further action was needed. Additionally, the PCC stated Resident #1 fell again on 04/20/17 and the nursing assessment revealed the resident sustained [REDACTED]. She stated the bed alarm malfunctioned during the fall and the resident was not wearing non-skid footwear again. The alarm was thrown away and a new one placed. The PCC stated it did not occur to her that a malfunctioning alarm needed to be investigated to determine the cause and/or identify possible trends that would necessitate a corrective action plan to ensure resident safety. The PCC stated at times she would find bed/chair alarms turned off or with frayed wires. However, she did not identify the need for a formal auditing process or that re-education was needed, related to the monitoring of bed/chair alarms for placement and functionality. She stated the root cause analysis was a process to determine what happened and for the facility to put actions in place to promote resident safety and it looked like there was opportunity for improvement. Interview, on 05/25/17 at 10:35 AM, with the DON revealed the interdisciplinary team reviewed falls each morning. However, after Resident #1's two (2) falls, it was not identified that a formal auditing process or an action plan was needed to address the malfunctioning bed alarm or the lack of non-skid footwear. She stated she performed rounds of the facility and at times found bed/chair alarms not functioning. She stated she expected staff to ensure the alarms were in place and functioning. She stated she was not looking for trends with malfunctioning bed/chair alarms but should have been. She stated the root cause analysis was a process to help the facility determine where the system breakdown occurred so they could put corrective actions in place. Per interview, the facility process did not identify the need for a corrective action plan related to Resident #1's fall but should have. Interview, on 05/25/17 at 11:10 AM, with the Administrator revealed he was ultimately responsible for resident care in the facility. He stated resident falls were discussed in the morning meeting along with the contributing factors and root causes. He stated he directed staff to follow-up and address the identified contributing factors and believed the staff was doing as directed. He stated it was the responsibility of his management staff to monitor for the implementation of fall prevention measures. Per interview, neither the Administrator nor his staff could provide evidence of an action plan or audits related to Resident #1 and Resident #7's falls. He stated the facility would not be meeting the care needs of the residents and harm could occur if hazards and fall risks were not identified and addressed timely.

Based on interview, record review, and policy review it was determined the facility failed to ensure care plan interventions for residents at risk for falls were implemented for two (2) of seven (7) sampled residents, Resident #1 and #7. Review of Resident #7's plan of care, dated 12/05/16, revealed staff should ensure the resident wore non-skid footwear. Record review revealed Resident #7 fell on [DATE] and 05/08/17 while ambulating without non-skid footwear. The resident sustained [REDACTED]. Review of Resident #1's fall risk care plan, dated 05/07/17, revealed the resident should have non-skid socks in place when not wearing shoes. Record review revealed Resident #1 fell on [DATE] and 04/20/17 while ambulating without non-skid socks. On 04/20/17, Resident #1 was found on the floor next to the bed with blood oozing from both nostrils and a hematoma (collection of blood under the skin) to the back of the head as a result of the fall. The findings include: Review of the facility policy titled, Fall Prevention, dated March 2017, revealed the completed Fall Risk Assessment would be reviewed by the interdisciplinary team for all residents with increased risk of falls. The fall risk approaches would be included in the plan of care for implementation. Review of the policy titled, Comprehensive Care Plan, dated January 2017, revealed all care plans would be reviewed and updated as needed with any acute illness or change in condition to reflect the current care the resident receives. 1. Review of Resident #7's clinical record on 05/23/17 revealed, the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 01/24/17, revealed the resident was not interviewable. Review of Resident #7's comprehensive plan of care, developed on 12/05/16, revealed the resident was at risk for falls related to impaired balance and advancing age. The goal was for the resident to remain free of injures related to falls. The approaches stated the staff was to provide verbal reminders to not ambulate or transfer without assistance; as able to understand. Staff was to ensure the resident wore properly fitting non-skid footwear for ambulation and/or transfers. Continued review of Resident #7's plan of care revealed after the fall on 03/27/17 staff wrote on the plan of care to reinforce use of the call light with the resident and use of non-skid socks. Review of Nursing Documentation, dated 03/27/17, revealed Resident #7 fell trying to use the bathroom. The resident hit the back of his/her head on the bathroom door and sustained a fractured left hip. Review of the Fall Scene Report, dated 03/27/17, revealed the resident was wearing slippers, lost his/her balance, and slipped at the time of the fall. Interview with Certified Nursing Assistant (CNA) #7, on 05/24/17 at 3:45 PM, revealed he was assigned to care for the resident on 03/27/17 and found the resident on the floor in the bathroom. He stated he was not sure if the resident had non-skid foot wear on the plan of care; but stated most residents do, for fall prevention. He stated staff must follow care plan interventions to protect residents from injuries. Interview, on 05/23/17 at 9:05 PM, with Registered Nurse (RN) #1, revealed Resident #7 had walked unassisted to the bathroom to toilet self and fell . She stated according to her documentation the resident was wearing slippers, tripped and fell . She stated she could not remember if non-skid footwear was an intervention on Resident #7's plan of care but most residents wore them. She stated it was the responsibility of staff to ensure the resident wore the non-skid footwear. She stated if staff did not follow the plan of care, resident harm could occur. Review of Nursing Documentation, dated 05/08/17, revealed Resident #7 fell and sustained a skin tear to the right arm while trying to remove a wandering resident from his/her room. Review of the Fall Scene Report, dated 05/08/17, revealed the resident was wearing compression stockings at the time of the fall, not non-skid footwear. Interview with CNA #16 on 05/23/17 at 2:50 PM and CNA #15, on 05/24/17 at 2:20 PM revealed neither one knew if Resident #7 had non-skid socks on at the time of the fall. Both stated if staff did not follow a resident's fall care plan interventions, residents could fall and be injured. Interview with the Patient Care Coordinator (PCC), on 05/25/17 at 12:00 PM, revealed Resident #7 fell and fractured the left hip on 03/27/17 and then fell again on 05/08/17 and received a skin tear to the right arm. She stated after each fall she reviewed the Fall Scene Report and it was identified that staff had not ensured the resident wore the non-skid footwear. She stated staff was to implement care plan interventions related to fall risk in order to decrease injury and falls. She stated she had not followed up with staff to re-educate or ensure they implemented the plan of care related to the non-skid footwear. She stated if staff did not follow care plan interventions, resident care needs would not be met. Interview with the Director of Nursing (DON), on 05/25/17 at 10:35 AM, revealed she had not determined there was an issue with staff not implementing Resident #7's fall care plan interventions. She stated she expected staff to implement fall risk interventions such as ensuring Resident #7 had on non-skid foot wear to decrease the chance of falling or sustaining an injury. She stated if staff did not implement the care plan resident harm could occur. 2. Review of Resident #1's clinical record, on 05/22/17, revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/03/17, revealed the resident was not interviewable. Review of Resident #1's comprehensive plan of care, developed on 05/07/17, revealed the resident was at risk for falls. The goal was for the resident to remain free of injures related to falls. The approaches stated the resident was to wear non-skid socks when not wearing shoes, non-skid strips to the floor, and give verbal reminders not to ambulate without assistance as able to understand. Review of the Fall Scene Investigation report, dated 04/20/17, revealed Resident #1 was easily agitated and disoriented prior to the fall; and nursing administered [MEDICATION NAME] within eight (8) hours of the fall. The report noted injuries from the fall were a hematoma (collection of blood under the skin) to the back of the head and bright red blood oozing from both nostrils. The report stated the resident complained of pain in both legs and the right hip after the fall. The fall contributing factors noted on the report revealed the resident was not wearing non-skid socks at the time of the fall. Interview with CNA #7, on 05/25/17 at 2:15 PM, revealed she found Resident #1 on the floor beside the bed with blood coming out of the nose and a hematoma to the back of the head. She stated she did not remember if the resident had on non-skid socks but she thought the resident only wore the non-skid socks when sitting in the recliner. She stated it was important to follow fall care plan interventions because they reduced resident fall risk. Interview, on 05/23/17 at 9:05 PM, with RN #1 revealed Resident #1 was found on the floor beside the bed with blood oozing from both nostrils and a hematoma to the back of the head. She stated during her assessment she noted the resident did not have on non-skid socks as per the nursing plan of care. However, she did not remember if she coached the staff regarding the lack of non-skid footwear. She stated following care plan interventions reduced resident fall risk and injuries. She stated if the care plan was not followed resident's needs would not be met. Interview with the PCC, on 05/25/17 at 12:05 PM, revealed Resident #1 had no safety awareness and was confused. She stated she reviewed the Fall Scene Investigation report and determined the staff failed to ensure the resident had non-skid socks in place while in bed per the physician's order and resident's plan of care. She stated she expected the nurse to follow-up with the certified nursing assistants assigned to the resident regarding the importance of following care plan interventions. She stated part of her role was also to follow-up with the aides to re-enforce the importance of following the plan of care. However, she did not follow-up with the aides after Resident #1's fall, and was not sure why she did not. She stated implementing fall care plan interventions helped to decrease falls and resident injuries. Interview with the DON, on 05/25/17 at 10:35 AM, revealed it was her responsibility to monitor staff implementation of residents' care plan interventions. She stated Resident #1's fall was discussed in the morning meeting on 04/21/17; however, she did not assign someone to follow-up or provide education to ensure staff followed the fall care plan interventions related to the non-skid socks. She stated it was important for staff to follow care plan interventions in order to reduce resident fall risk and injuries. Interview, on 05/25/17 at 11:10 AM, with the Administrator revealed he was ultimately responsible for resident care in the facility. He stated resident falls were discussed in the morning meeting along with the contributing factors. He stated he directed staff to follow-up on the identified contributing factors and believed the staff was doing as directed. Per interview, he performed walking rounds and directed his management staff to do the same to monitor for care plan interventions; however no documented formal audits were completed. He revealed if staff did not implement the plan of care the facility would not be meeting the care needs of the residents.

Based on interview, record review, and policy review it was determined the facility failed to ensure care plan interventions for residents at risk for falls were implemented for two (2) of seven (7) sampled residents, Resident #1 and #7. Review of Resident #7's plan of care, dated 12/05/16, revealed staff should ensure the resident wore non-skid footwear. Record review revealed Resident #7 fell on [DATE] and 05/08/17 while ambulating without non-skid footwear. The resident sustained [REDACTED]. Review of Resident #1's fall risk care plan, dated 05/07/17, revealed the resident should have non-skid socks in place when not wearing shoes. Record review revealed Resident #1 fell on [DATE] and 04/20/17 while ambulating without non-skid socks. On 04/20/17, Resident #1 was found on the floor next to the bed with blood oozing from both nostrils and a hematoma (collection of blood under the skin) to the back of the head as a result of the fall. The findings include: Review of the facility policy titled, Fall Prevention, dated March 2017, revealed the completed Fall Risk Assessment would be reviewed by the interdisciplinary team for all residents with increased risk of falls. The fall risk approaches would be included in the plan of care for implementation. Review of the policy titled, Comprehensive Care Plan, dated January 2017, revealed all care plans would be reviewed and updated as needed with any acute illness or change in condition to reflect the current care the resident receives. 1. Review of Resident #7's clinical record on 05/23/17 revealed, the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 01/24/17, revealed the resident was not interviewable. Review of Resident #7's comprehensive plan of care, developed on 12/05/16, revealed the resident was at risk for falls related to impaired balance and advancing age. The goal was for the resident to remain free of injures related to falls. The approaches stated the staff was to provide verbal reminders to not ambulate or transfer without assistance; as able to understand. Staff was to ensure the resident wore properly fitting non-skid footwear for ambulation and/or transfers. Continued review of Resident #7's plan of care revealed after the fall on 03/27/17 staff wrote on the plan of care to reinforce use of the call light with the resident and use of non-skid socks. Review of Nursing Documentation, dated 03/27/17, revealed Resident #7 fell trying to use the bathroom. The resident hit the back of his/her head on the bathroom door and sustained a fractured left hip. Review of the Fall Scene Report, dated 03/27/17, revealed the resident was wearing slippers, lost his/her balance, and slipped at the time of the fall. Interview with Certified Nursing Assistant (CNA) #7, on 05/24/17 at 3:45 PM, revealed he was assigned to care for the resident on 03/27/17 and found the resident on the floor in the bathroom. He stated he was not sure if the resident had non-skid foot wear on the plan of care; but stated most residents do, for fall prevention. He stated staff must follow care plan interventions to protect residents from injuries. Interview, on 05/23/17 at 9:05 PM, with Registered Nurse (RN) #1, revealed Resident #7 had walked unassisted to the bathroom to toilet self and fell . She stated according to her documentation the resident was wearing slippers, tripped and fell . She stated she could not remember if non-skid footwear was an intervention on Resident #7's plan of care but most residents wore them. She stated it was the responsibility of staff to ensure the resident wore the non-skid footwear. She stated if staff did not follow the plan of care, resident harm could occur. Review of Nursing Documentation, dated 05/08/17, revealed Resident #7 fell and sustained a skin tear to the right arm while trying to remove a wandering resident from his/her room. Review of the Fall Scene Report, dated 05/08/17, revealed the resident was wearing compression stockings at the time of the fall, not non-skid footwear. Interview with CNA #16 on 05/23/17 at 2:50 PM and CNA #15, on 05/24/17 at 2:20 PM revealed neither one knew if Resident #7 had non-skid socks on at the time of the fall. Both stated if staff did not follow a resident's fall care plan interventions, residents could fall and be injured. Interview with the Patient Care Coordinator (PCC), on 05/25/17 at 12:00 PM, revealed Resident #7 fell and fractured the left hip on 03/27/17 and then fell again on 05/08/17 and received a skin tear to the right arm. She stated after each fall she reviewed the Fall Scene Report and it was identified that staff had not ensured the resident wore the non-skid footwear. She stated staff was to implement care plan interventions related to fall risk in order to decrease injury and falls. She stated she had not followed up with staff to re-educate or ensure they implemented the plan of care related to the non-skid footwear. She stated if staff did not follow care plan interventions, resident care needs would not be met. Interview with the Director of Nursing (DON), on 05/25/17 at 10:35 AM, revealed she had not determined there was an issue with staff not implementing Resident #7's fall care plan interventions. She stated she expected staff to implement fall risk interventions such as ensuring Resident #7 had on non-skid foot wear to decrease the chance of falling or sustaining an injury. She stated if staff did not implement the care plan resident harm could occur. 2. Review of Resident #1's clinical record, on 05/22/17, revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 02/03/17, revealed the resident was not interviewable. Review of Resident #1's comprehensive plan of care, developed on 05/07/17, revealed the resident was at risk for falls. The goal was for the resident to remain free of injures related to falls. The approaches stated the resident was to wear non-skid socks when not wearing shoes, non-skid strips to the floor, and give verbal reminders not to ambulate without assistance as able to understand. Review of the Fall Scene Investigation report, dated 04/20/17, revealed Resident #1 was easily agitated and disoriented prior to the fall; and nursing administered [MEDICATION NAME] within eight (8) hours of the fall. The report noted injuries from the fall were a hematoma (collection of blood under the skin) to the back of the head and bright red blood oozing from both nostrils. The report stated the resident complained of pain in both legs and the right hip after the fall. The fall contributing factors noted on the report revealed the resident was not wearing non-skid socks at the time of the fall. Interview with CNA #7, on 05/25/17 at 2:15 PM, revealed she found Resident #1 on the floor beside the bed with blood coming out of the nose and a hematoma to the back of the head. She stated she did not remember if the resident had on non-skid socks but she thought the resident only wore the non-skid socks when sitting in the recliner. She stated it was important to follow fall care plan interventions because they reduced resident fall risk. Interview, on 05/23/17 at 9:05 PM, with RN #1 revealed Resident #1 was found on the floor beside the bed with blood oozing from both nostrils and a hematoma to the back of the head. She stated during her assessment she noted the resident did not have on non-skid socks as per the nursing plan of care. However, she did not remember if she coached the staff regarding the lack of non-skid footwear. She stated following care plan interventions reduced resident fall risk and injuries. She stated if the care plan was not followed resident's needs would not be met. Interview with the PCC, on 05/25/17 at 12:05 PM, revealed Resident #1 had no safety awareness and was confused. She stated she reviewed the Fall Scene Investigation report and determined the staff failed to ensure the resident had non-skid socks in place while in bed per the physician's order and resident's plan of care. She stated she expected the nurse to follow-up with the certified nursing assistants assigned to the resident regarding the importance of following care plan interventions. She stated part of her role was also to follow-up with the aides to re-enforce the importance of following the plan of care. However, she did not follow-up with the aides after Resident #1's fall, and was not sure why she did not. She stated implementing fall care plan interventions helped to decrease falls and resident injuries. Interview with the DON, on 05/25/17 at 10:35 AM, revealed it was her responsibility to monitor staff implementation of residents' care plan interventions. She stated Resident #1's fall was discussed in the morning meeting on 04/21/17; however, she did not assign someone to follow-up or provide education to ensure staff followed the fall care plan interventions related to the non-skid socks. She stated it was important for staff to follow care plan interventions in order to reduce resident fall risk and injuries. Interview, on 05/25/17 at 11:10 AM, with the Administrator revealed he was ultimately responsible for resident care in the facility. He stated resident falls were discussed in the morning meeting along with the contributing factors. He stated he directed staff to follow-up on the identified contributing factors and believed the staff was doing as directed. Per interview, he performed walking rounds and directed his management staff to do the same to monitor for care plan interventions; however no documented formal audits were completed. He revealed if staff did not implement the plan of care the facility would not be meeting the care needs of the residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the environment was free from potential accidents and hazards as evidenced by water temperatures measured greater than one hundred ten degrees Fahrenheit (110 F) on four (4) of five (5) hallways. In addition, the facility had two (2) unlocked storage closets containing razors, other sharps, and personal care substances such as denture cleansers, enemas, disinfectant wipes, and body wash. Further, a medication cart was observed unlocked and unsupervised on Cherry Lane. The findings include: 1. Review of the facility's Maintenance and Repairs policy, dated March 2009, revealed the facility maintenance department was responsible for maintaining the hot water used by residents at a temperature between one hundred (100) and one hundred ten (110) degrees Fahrenheit (F). The policy stated control valves should automatically regulate the system and the maintenance department keeps the plumbing fixtures in good repair. Review of the Maintenance Schedule policy, dated January 2017, revealed the facility performed routine facility maintenance by checking hot water heater temperatures weekly. The hot water temperature in resident areas did not exceed one hundred ten (110) degrees. Observations of water temperatures, on 03/14/17 at 2:00 PM, revealed the water temperature in Room #46 measured one hundred fourteen (114) degrees. The water temperature in Room #41 measured one hundred twelve (112) degrees. The water temperature in Room #7 measured one hundred sixteen (116) degrees. The water temperature in Room #14 measured one hundred sixteen (116) degrees. The water temperature in Room #28 measured one hundred fourteen (114) degrees. The water temperature in Room #31 measured one hundred fourteen (114) degrees. Review of the Water Temperature Checklist log, from 12/02/16 through 03/10/17, revealed the maintenance department monitored water temperatures in various rooms and on each hallway on a weekly basis. The Maintenance Department recorded temperatures between ninety-nine (99) and one hundred ten (110) degrees. Observations of the Maintenance Director taking water temperatures, on 03/14/17 at 3:30 PM, revealed the Maintenance Director used a handheld digital thermometer to obtain water temperatures in resident areas. From the handheld portion of the device was a cord that was frayed near the base where it connected to the device. The Maintenance Director placed the other end of the cord into running water to obtain water temperature readings. Interview with the Maintenance Director, on 03/14/17 at 3:30 PM, revealed he monitored water temperatures weekly on Fridays using the same thermometer. He stated he never calibrated the thermometer to ensure accurate measurements and readings. After taking water temperatures again with a thermometer from the kitchen, the Maintenance Director stated the water temperature readings measured higher than one hundred ten (110) degrees. He stated the kitchen thermometer measured approximately twelve (12) degrees warmer than his digital thermometer. Interview with the Director of Nursing (DON), on 03/16/17 at 1:00 PM, revealed she was unaware the facility water temperatures were above one hundred ten (110) degrees. She stated she had received no grievances related to high water temperature. She further stated the facility had no reports of residents burned due to high water temperatures. Interview with the Administrator, on 03/16/17 at 1:20 PM, revealed he was unaware the facility's water temperature was above one hundred ten (110) degrees. He stated high water temperature posed a potential risk to residents. The Administrator stated the Maintenance Director obtained weekly water temperatures; however, he stated the thermometer used was inaccurate. 2. Review of the Maintenance and Repairs policy, dated March 2009, revealed the facility's maintenance department was responsible to maintain the interior of the building at all times. The Maintenance department maintained the building in compliance with federal, state, and local laws and performed routine maintenance task on resident equipment and supplies. The Maintenance Department also made minor repairs as needed. Review of the Maintenance Schedule policy, dated January 2017, revealed the Maintenance Schedule included checking door alarms and door connections periodically. Review of the facility's policy, Medication Storage in the Facility, undated, revealed the facility stored potentially harmful substances, such as cleaning supplies and disinfectants, in a locked area. Review of the facility's policy, Interior and Exterior Access Security, dated March 2009, revealed the facility ensured all doors were secured in order to assure the safety of residents. The facility's electronically locked interior security doors were electronically locked and granted access by entering the correct code into the keypad. Review of the Safety Data Sheet (SDS) for Alcohol-Free Mouthwash, revised 01/15/16, revealed the substance caused slight eye irritation. Review of the SDS for Shaving Cream, revised 05/08/15, revealed the material contained gas under pressure and caused eye irritation. Review of the SDS for Sterile Alcohol Prep Pads, revised 10/27/16, revealed the material was acutely toxic if ingested and caused eye damage and irritation. Review of the SDS for Denture Tabs, undated, revealed the substance should not be placed in the mouth. The material contained Persulfate and could cause an allergic reaction. Review of the SDS for shampoo and body wash, revised 05/30/15, revealed the material caused acute toxicity from oral ingestion and eye damage. Observations of the facility during the environmental tour, on 03/14/17 at 1:00 PM, revealed on the South Unit, the clean linen room doorknob contained a push button code keypad lock. However, the door was not latched and the room was accessible to residents. When allowed to swing shut, the door did not fully latch. The clean linen room contained personal hygiene supplies including: one (1) box of ninety (90) count effervescent denture cleanser tablets; three (3) boxes of one point five ounce (1.5 oz.) tubes of toothpaste; one (1) eleven ounce (11 oz.) can of shaving cream; two (2) four ounce (4 oz.) bottles of alcohol free mouth wash; and eight (8) eight ounce (8 oz.) bottles of moisturizing shampoo and body wash. Continued observations during the environmental tour revealed an unlocked storage area in the North Unit's Central Supply room. The Central Supply room doorknob contained a push button code keypad lock. However, the keypad was not engaged and the door handle turned, opening the door into the Central Supply room. The room contained one hundred ten (110) disposable razors, boxes of syringes, boxes of two hundred (200) count alcohol prep pads, ninety-six (96) bottles of alcohol free mouth wash, bottles of skin repair cream, boxes of enemas, and boxes of moisturizing shampoo and body wash. Observation of the Central Supply room, on 03/15/17 at 11:30 AM and 2:10 PM, revealed the door was unlocked and the room was accessible to residents. Record Review of the Maintenance Log on the South Wing, dated from 01/07/17 to 03/15/17, revealed staff had not entered a work request pertaining to the door of the clean linen room not latching. Record Review of the Maintenance Log on the North Unit, dated from 01/01/17 through 03/15/17, revealed staff had made no requests to fix the lock on the Central Supply door. Interview with Certified Nursing Assistant (CNA) #3, on 03/16/17 at 9:11 AM, revealed she obtained needed personal supplies for residents from the stock room and from the Clean Linen room on the South Unit. She stated she used a code to gain entry to the clean linen room. The CNA stated she was unaware the door to the clean linen room did not latch because she had never tried to open it without putting in the code on the lock. Interview with Licensed Practical Nurse (LPN) #2, on 03/16/17 at 9:20 AM, revealed she was aware the facility stored syringes in the Central Supply room on the North Unit. She stated she was unaware the room was unlocked because she put the code in the lock each time she entered the room. She stated the door needed to remain locked because the room contained hazards such as syringes residents could hurt themselves with, shampoos residents could potentially ingest, and because a resident could pull other items down on top of themselves. Observation of the Central Supply room, on 03/16/17 at 11:00 AM, revealed the door opened by turning the handle without inputting the code on the door lock. During the observation, a resident opened the door and entered the room asking if it was the bathroom. The Staffing Coordinator was present in the room at the time and redirected the resident. Interview with the Staffing Coordinator, on 03/16/17 at 11:00 AM, revealed she was unaware the lock to the Central Supply room was not functioning. She stated she was responsible for the Central Supply room and her office was located in the back of the Central Supply room. She stated she always put the code into the door lock and did not notice the door could open without entering the code. She stated she became aware of the broken door lock on 03/16/17, while unpacking boxes. She stated she had not yet written the maintenance request in the maintenance request log. The Staffing Coordinator stated the unlocked door posed a risk as a resident could get into the room and have access to hazardous items if she were not in the room. She stated she was also unaware the door to the clean linen room on the South Unit was not latching and locking properly. Interview with the Director of Nursing, on 03/16/17 at 1:00 PM, revealed unlocked doors to the clean linen room on the South Unit and to the Central Supply room on the North Unit were a concern as a resident could enter one of the rooms and access hazardous items such as denture tablets or razors. She stated she did not check doors while rounding to ensure they locked and latched properly. Interview with the Maintenance Technician, on 03/16/17 at 2:25 PM, revealed he participated in the scheduled rounds of the facility. However, he stated he did not check the doors to locked areas of the facility. He stated staff reported issues with doors by writing maintenance concerns in the maintenance log. However, if staff did not report an issue with the internal doors, he did not check the internal locked doors on any regular basis. Interview with the Administrator, on 03/16/17 at 1:20 PM, revealed he was unaware the doors to the Clean linen room on the South Unit and to the Central Supply room on the North Unit had locks that did not function. He stated residents should not have access to those areas as they contained items that could be harmful to the residents. The Administrator stated the Maintenance Department completed facility rounding; however, he was unsure if the rounding included checking the function of doors to locked areas of the facility. 3. Review of the facility's policy, Accidents and Incidents, dated 01/05/15, revealed the facility maintained a safe and healthy environment. An accident/incident was defined as an occurrence with potential for injury, illness, altercation, etc., that resulted in personal injury or illness to a resident, employee, or visitor. Review of the facility's policy, Medication Storage in the Facility, not dated, revealed medications were stored safely, securely, and properly. The medication supply was accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies were locked or attended by persons with authorized access. Observation of Cherry Lane, on 03/14/17 at 3:48 PM and 4:07 PM, revealed Registered Nurse (RN) #3 walked away from the medication cart and left it unlocked and unsupervised. Observation of Cherry Lane, on 03/15/17 at 3:20 PM, revealed the medication cart in the hallway outside room 13 was unlocked and unsupervised. RN #3 was in room 13 on the other side of the drawn privacy curtain, out of view of the medication cart. Observation during medication administration, on 03/15/17 at 3:35 PM, revealed RN #3 left the medication cart, located on Cherry Lane, without locking the medication cart. RN #3 returned with the Director of Nursing (DON) and both walked by the unlocked medication cart and into a resident room, out of view of the unlocked medication cart. Interview with RN #3, on 03/16/17 at 1:45 PM, revealed staff was to lock all medication carts at all times unless the carts were in sight. RN #3 stated a locked medication cart prevented unauthorized access of medications by residents who may swallow the medications and suffer negative effects. RN #3 did not know why he left the medication cart unattended and unsecured. Interview with RN #2, Unit Manager for the North Wing, on 03/16/17 at 1:48 PM, revealed staff was to lock medication carts when unattended. RN #2 stated a locked medication cart prevented anyone, especially a resident, from gaining access to potentially harmful medications and harming themselves or another resident. Interview with the DON, on 03/16/17 at 2:14 PM, revealed staff was to lock medication carts anytime they were unattended, including when stored in the storage room. The DON stated a locked medication cart was for resident safety and prevented residents from accessing and consuming potentially harmful substances. The DON stated she rounded the facility daily and checked for unlocked medications carts; however, she did not document her rounds.

Based on interview and record review it was determined the facility failed to have an effective system in place to ensure immediate notification of the attending physicians and resident representatives after a fall for three (3) of thirty-two (32) sampled residents (Resident's #13, #15, and #20). (Refer to F323) On [DATE] at 5:30 AM, Resident #20 sustained a fall with injury. The resident sustained [REDACTED]. The facility did not notify the physician or the responsible party of the injury until three and half (3.5) hours later at 9:00 AM on [DATE]. Resident #20 sustained another fall on [DATE] at 11:55 PM, and the physician was not notified of the fall until almost eight and one-half (8.5) hours later at 8:30 AM on [DATE]. In addition, the facility did not notify the resident's responsible party of the fall on [DATE] until 8:40 AM on [DATE] when preparations were underway to transfer the resident to the emergency room . The resident expired at the hospital at 6:00 AM on [DATE]. Record review and interview revealed Resident #20 had sustained a fall on [DATE] with no evidence the physician was notified and fell on [DATE] and [DATE] and the resident's physician was not notified timely. On [DATE] at 3:20 AM, Resident #15 sustained a fall which resulted in a laceration to the left eyebrow. The physician was not notified until seven and one-half (7.5) hours later. On [DATE] at 11:20 AM, Resident #15 fell and sustained an injury to the right shoulder and hit his/her head. The Nurse Practitioner was not notified until the next day. Resident #15 fell on [DATE] at 9:15 AM and received an abrasion to the mid upper back and a skin tear to the right elbow. The physician was not notified until the next day. On [DATE], Resident #13 was found crawling on the floor mat beside their bed at 12:30 AM; found at 4:40 AM, crawling on the floor; and, at 7:10 AM, was found again crawling on the floor with a small laceration to the back of the head. The resident's physician was not notified of the 12:30 AM or the 4:40 AM fall until after the 7:10 AM fall occurred. On [DATE] the resident sustained [REDACTED]. The facility's failure to have an effective system in place for notification of the physician and responsible party in a timely manner has caused or is likely to cause serious injury, harm, impairment or death to resident. The Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE]. The scope and severity was lowered to an "E" while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of facility's policy Changes in a Resident's Condition or Status, dated [DATE], revealed the policy did not reflect timeframes to notify the physician or representative after a resident fall or change in condition/treatment. The policy stated nursing would notify the resident's attending physician and nursing or Social Services would notify the resident's representative when the resident was involved in any incident or accident; if there was a significant change in the resident's physical, mental, or psychosocial status; if there was a need to alter treatment significantly i.e. if the resident refused treatment or medications on a routine basis; or if the resident was discharged or transferred. All notifications would be documented in the resident's medical record. 1. Review of the closed clinical record for Resident #20 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #20 also had a history of [REDACTED]. Review of Resident #20's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident as not steady on his/her feet and needed extensive assistance from staff to toilet, walk, and bathe. A Brief Interview for Mental Status (BIMS) was conducted during the assessment and the resident scored an eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of the Fall Scene Investigation Report, dated [DATE] at 5:30 AM, revealed Resident #20 sustained a fall with injury. The report stated the resident sustained [REDACTED]. The facility did not notify the physician or the responsible party of the injury until three and one-half (3.5) hours later at 9:00 AM on [DATE]. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #20 sustained a fall on [DATE] at 11:55 PM, and the physician was not notified of the fall until eight and one-half (8.5) hours later at 8:30 AM on [DATE]. In addition, the facility did not notify the resident's responsible party of the fall on [DATE] until 8:40 AM on [DATE] when preparations were underway to transfer the resident to the emergency room . Review of the nursing notes, dated [DATE] at 11:55 AM, revealed the resident lost his/her balance, fell and hit his/her head on the foot board of the roommate's bed. There was no evidence in the nurses notes that the physician or the responsible party were notified of the fall. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 10:55 AM, revealed she consulted with another nurse regarding contacting the physician the night Resident #20 fell . The LPN stated due to the fall occurring at 11:55 PM and they knew the physician would be in the facility in the morning; the decision was made to notify the physician when he arrived that morning. Continued review of nursing documentation, dated [DATE] as a late entry, at 8:25 AM, revealed the resident was found by staff unresponsive, breathing irregularly and gurgling. The physician was noted to be in the facility at this time and was notified of the resident's change in condition. The physician ordered the resident to be sent to the emergency room of choice for evaluation on [DATE] at 8:30 AM. The facility notified the responsible party at 8:40 AM regarding the change in condition and their hospital of choice. Interview with Resident #20's Responsible Party (RP), on [DATE] at 4:05 PM, revealed the facility did not contact them at the time of Resident #20's fall; it was not until the facility was in the process of transferring the resident to the emergency department were they notified of the fall. Review of Resident #20's emergency room record, dated [DATE] and timed at 9:51 AM, revealed the resident's eyes were assessed upon admission and the findings revealed the left pupil to be dilated (indicating neurological changes). An X-ray of the brain was ordered immediately and results communicated to the emergency room physician at 10:25 AM that revealed a large brain bleed. Further review of Resident #20's Fall Scene Investigation reports, revealed on [DATE] Resident #20 fell at 5:45 PM and the physician was not notified until two hours later with message left on the answering machine. There was no evidence the physician was ever made aware of the fall. On [DATE] the resident fell at 11:15 AM, the Advanced Practice Registered Nurse (APRN) was notified at 6:45 PM. The resident sustained [REDACTED]. per the nurses notes. On [DATE] the resident fell at 12:00 PM and the APRN was notified at 1:15 PM. Attempted interview with Resident #20's attending physician, on [DATE] at 1:55 PM, revealed he was unable to discuss the resident without looking at the chart. He further stated he was not available for interview. Interview, on [DATE] at 3:00 PM, with the Director of Nursing (DON) revealed he met with LPN #10 on [DATE] to discuss Resident #20's fall. He stated it was at that time he determined the physician was not notified timely of the resident's fall. His expectation was that the physician be notified promptly after Resident #20's fall. 2. Review of the clinical record revealed the facility admitted Resident #15 on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed Resident #15 had a history of [REDACTED]. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident as not steady on his/her feet and needed extensive assistance from staff to toilet, walk, transfer and bathe. The MDS further revealed staff could not conduct a Brief Interview for Mental Status (BIMS) due to the resident having short-term and long-term memory problems which affected his/her ability to make decisions and follow cues. The facility determined on the MDS the resident required supervision in daily decision making. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 fell on [DATE] at 3:20 AM. Facility staff reported Resident #15 was getting up from the recliner in the common area to go to the toilet when he/she fell . The Fall Scene Investigation report noted the resident fell face down onto the floor from the recliner and received a five-tenths (.5) centimeter (cm) laceration to the side of the left eyebrow which was swollen, raised and bruised. The Fall Scene Investigation report also noted Resident #15 reported the laceration was burning. Review of the nurse's notes for Resident #15, dated [DATE] at 1:40 PM, revealed the nurse informed the resident's physician of the resident's 3:20 AM fall, seven and one-half (7.5) hours after the fall. Further review of the note dated [DATE] at 2:25 PM revealed steri strips were applied at that time to a five-tenths (.5) centimeter (cm) laceration to Resident #15's left eyebrow. The nurse also noted on [DATE] at 2:25 PM the resident had a bruise on his/her left wrist. Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell on [DATE] at 11:20 PM. The resident reported hitting his/her head at the time of the fall and complained of pain in the right shoulder. The Fall Scene Investigation report indicated neurological checks were initiated but no other treatment given. Review of the nursing notes, dated [DATE] at 9:30 AM, revealed nursing staff notified the resident's Advanced Practice Registered Nurse (APRN) of the fall which had occurred at 11:20 PM on [DATE], ten (10) hours after the fall. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 fell on [DATE] at 9:15 AM. The fall report stated the resident was getting up to use the toilet and was incontinent of urine at the time of the fall. The resident received an abrasion to the mid upper back and a skin tear on the right elbow about 1.8 cm long. The Nursing notes, dated [DATE] at 10:40 AM, revealed Resident #15 complained of right side pain and the physician was notified at that time of the fall which had occurred at 9:15 AM on that date, one and one-half (1.5) hours. 3. Review of the clinical record for Resident #13 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Comprehensive Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident triggered as a falls risk and did not ambulate, but utilized a wheelchair for mobility. Review of the Quarterly MDS assessment, dated [DATE], revealed Resident #13 required the assistance of one (1) staff member for transfers. Review of Resident #13's Comprehensive Care Plan revealed interventions for falls prevention. Review of the Comprehensive Falls care plan revealed that prior to Resident #13's admission to the facility he/she had a history of [REDACTED]. Interview, on [DATE] at 12:05 PM, with LPN #5 revealed it was her understanding that prior to Resident #13's admission to the facility, he/she had crawled from chairs/furniture to the floor at home, as a means of getting around, and the resident had exhibited this behavior as a means of transfer/locomotion at the facility, as well. Review of the resident's clinical record (nurses' notes), revealed on [DATE] at 12:30 AM, Resident #13 was found by staff crawling on the floor mat beside his/her bed. At 4:40 AM, after the resident was transferred by staff, per wheelchair, to the sitting area on the Orchard Unit, the resident's wheelchair alarm sounded and he/she was found crawling on the floor. Further review of the nurses' notes revealed, on [DATE] at 7:10 AM, Resident #13 was again found on the floor of the unit's day room/sitting area. The resident was positioned on the floor between his/her wheel chair and another chair. The resident was assessed and a small laceration (,[DATE] centimeters) was found at the back of his/her head. Review of the falls reports, dated [DATE] at 12:30 AM, at 4:40 AM, and at 7:10 AM, did not reveal Resident #13's physician was immediately notified of the falls that occurred at 12:30 AM and 4:40 AM, but was notified at 7:10 AM after the third fall when a laceration was found on the back of the resident's head. Further review of Resident #13's Nursing Notes, dated [DATE] and timed at 1:00 PM, revealed the housekeeping supervisor called the nurse to Resident #13's room where she found the resident lying on the floor with a laceration above the right eyebrow and a hematoma about the size of a golf ball above the right eye. Nursing documented the physicians' call center was notified of the resident's fall at 2:00 PM, one (1) hour after the fall. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 10:55 AM, revealed she was not sure what the facility policy directed them to do in regards to notifying the physician after a fall. Interview, on [DATE] at 3:00 PM, with the Director of Nursing (DON) revealed he had not conducted any recent audits to determine if there was a pattern in the facility of staff not notifying the physician timely. The DON stated no plans were made to conduct or re-educate staff. The DON stated he could not recall if not notifying physicians promptly was ever brought to the Quality Assurance Committee as an issue. He stated the importance of notifying the physician timely was to allow the physician the ability to direct the care of the resident. Review of the Allegation of Compliance (AOC) revealed the facility implemented the following immediate steps to remove the Immediate Jeopardy: 1. The Medical Director was notified of Immediate Jeopardy and incidents causing the Immediate Jeopardy on Thursday [DATE]. 2. A representative of the Governing Body provided the Administrator guidance and education on physician and family notification, supervision and investigation of falls, care plan revisions and scheduled toileting programs on [DATE] and [DATE]. 3. Licensed nurses (DON, Staff Development Coordinator, Risk Care Manager, Restorative/Wound Care Nurse, Minimum Data Set Nurse, House Supervisor, two (2) Unit Managers and a Staff Nurse) completed an audit on [DATE] for the one hundred eleven (111) residents currently in the facility. This included thirty (30) residents who had a fall in the past three (3) months, and eighty-one (81) residents who had no fall within the past three (3) months. The audit included a review of the fall event document for those who had fallen for root cause of the fall, interventions added to the care plans at the time of the fall, times of scheduled toileting program (if any), alarms utilized, care plans, notifications made to the attending physician and resident's responsible party and interventions added after the audit was completed. An action taken as a result of the audit included update/revision to care plans for eleven (11) residents. that included reachers; toileting in early morning hours; sensor pads; mattresses; and, non-skid strips to the floor. In addition, one resident's toileting program was addressed as a result of the [DATE] audit with changes to the timing of the toileting program based on his/her individualized needs. 4. The Medical Director met with the Director of Nursing (DON) on [DATE] to review policies, procedures and practices for physician notification, root cause analysis of accidents, incidents and falls prevention, revision of care plans and the scheduled toileting program. Revisions were made to the policy, Accident and Incidents, for physician and responsible party notification to include notification to the physician within thirty (30) minutes of a fall involving head injury or a fall which was not witnessed. Revision was made to the policy, Falls Prevention, to check safety devices each shift to ensure they are in place and functioning properly. 5. The procedure for conducting neurological checks was reviewed by the DON and the Staff Development Coordinator and all licensed nurses provided education on that process on [DATE] through [DATE]. The DON and the Staff Development Coordinator conducted the inservice training on neurological checks and additional pen lights (used to conduct the neurological checks) were ordered by the DON on [DATE]. 6. The MDS Coordinator, MDS Nurse, DON and Risk Manager are responsible for ensuring care plans are completed/revised in a timely/accurate manner. The care plans of residents who have fallen would be reviewed weekly in a Standards of Care meeting led by the MDS Nurse and the MDS Coordinator. In attendance at that meeting are the Dietary Manager, Risk Manager, Social Services Representative and the Activity Director. A report would be generated in that meeting of all falls, the review/revision of the residents' care plans and any actions taken to address concerns which would include staff education, staff discipline and care plan revisions to the Quality Assessment and Assurance Committee monthly from [DATE] - [DATE]. 7. The DON and the Staff Development Coordinator were provided training by the Administrator on [DATE] on physician and responsible party notification. The DON and the Staff Development Coordinator initiated all licensed nurses' and Certified Nursing Assistants' (CNA) training on [DATE] and continued that training through [DATE]. A total of one hundred nineteen (119) staff had been trained by 9:30 PM on [DATE] with one (1) remaining staff notified they must receive training by their supervisor prior to returning to work. The training to all licensed nurses and certified nursing assistants included: work order process, care plans, certified nursing assistant care sheets, proper use and types of alarms, the scheduled toileting program process/form to be used and proper completion of the form. The licensed nurses received training on: falls and proper process for notification of the resident's physician, the responsible party, the neurological check process, the proper completion of the Event Report Form, review/revision of care plans, root cause analysis process, policy and procedure on Accidents and Incidents, policy on Falls Prevention, Neurological check protocol form and the form used for the Scheduled Toileting Program. 8. The Administrator provided training to the Director of Nursing, the Risk Manager and therapy staff on [DATE] and [DATE] regarding the IJ, policy and procedure revisions, processes of Falls Committee Meeting, quality assessment and assurance committee role to ensure compliance and develop further actions to be taken. 9. Three (3) notifications of residents' who fell prior to [DATE] was made to the attending physicians and responsible party on [DATE] with one (1) physician and the responsible party notification of a fall which occurred on [DATE]. 10. A Falls Committee was initiated [DATE] to review fall interventions, to review reviewed/revised care plans and to complete root cause analysis for falls during the meeting. The Falls Committee is comprised of the Administrator, the DON, a MDS Nurse, Social Worker, Risk Care Manager, Restorative/Wound Care Nurse and the Rehabilitation Services Manager and meets Monday-Friday. 11. The DON provided training to the Restorative/Wound Care Nurse on [DATE], [DATE] and [DATE] addressing the facility's scheduled toileting program, the toileting program as it relates to falls, review of the four day bowel and bladder assessment process to note patterns and trends to develop an individualized scheduled toileting program for the resident, the process of documentation on the toileting program form and the creation of an audit tool to audit the clinical documentation relative to the toileting program, monitor for patterns and trends of the toileting program and a system to report findings of the audits to the Quality Assessment and Assurance Committee. 12. The Restorative/Wound Care Nurse would audit the toileting program using the Scheduled Toileting Audit tool. The toileting program documentation was to ensure accuracy and completeness of scheduled toileting programs. The audit would include completion of all fields on the toileting program document, issues noted, trends noted, updates to the toileting program and her initials. On [DATE] the Restorative/Wound Care Nurse audited twenty-nine (29) clinical records finding one (1) area of concern and on [DATE] she audited twenty-eight (28) clinical records finding one (1) area of concern. The Restorative/Wound Care Nurse is to report identified concerns with the toileting program to the DON and the Quality Assessment and Assurance Committee will review and monitor those findings. 13. The facility will utilize the Quality Assessment and Assurance Committee to review, evaluate and monitor for compliance with the notification of physician/responsible party, revision of resident care plans, toileting program and accidents and supervision with the following documents to be utilized: audits for falls, audits of notification of resident's attending physician/responsible party, audits of care plans addressing falls and audits of toileting program. The monthly meeting of the Quality Assessment and Assurance Committee to be held in February 2015 will be the initial meeting to review all of the audit information. These meetings will continue monthly for the next calendar year and will review the audit findings, assess the effectiveness of actions taken, revise action plans if necessary and continue to monitor the specifics of all falls within the facility. On [DATE], the State Survey Agency (SSA) validated the facility's AOC prior to exit through observation, interview and record review as follows: 1. Telephone interview with the Medical Director, on [DATE] at 2:30 PM, post survey due to lecture schedule and unavailability, revealed he was contacted by the Director of Nursing (DON) on [DATE] regarding the Immediate Jeopardy. The Medical Director revealed he and the DON discussed several issues in regard to the Immediate Jeopardy i.e. the cause of resident falls, toileting issues/toileting schedules, CNA education, review of residents' medications, use of non-skid socks/shoes (should always be available) and lighting. He also revealed he and the DON discussed revision of the residents' care plans as necessary and the revisions needed for facility policies; specifically Accidents/Incidents, Fall Prevention and the Toileting Program. The Medical Director indicated he told the DON the question should always be asked after a resident's fall where the facility failed and what should be done to prevent resident falls/accidents. 2. Review of the Administrator's notes from telephone conversation with a Governing Body representative revealed the representative retrained the Administrator on the need to ensure policies and procedures were in place (process of physician/family notification, supervision and falls, care plan revisions and scheduled toileting programs). Further review of the Administrator's notes from telephone conversation with a Governing Body representative on [DATE] revealed the representative addressed the process of root cause analysis which required intense and in-depth questioning, record review, and resident, staff and witness interviews. Also discussed during the [DATE] training of the Administrator by the Governing Body representative was tracking and trending of all falls and assurance audits are in place to ensure processes are being followed with concerns identified to be addressed in staff training. Interview with the Administrator, on [DATE] at 10:50 AM, revealed he had a telephone conversation with a Governing Body representative on [DATE] and [DATE] to include how to complete the process of physician/family notification when a resident had a fall, how to follow the facility policy regarding falls, care plan revisions, the scheduled toileting programs, and the process in-depth root cause analysis. 3. Review of the Resident Audit for Immediate Jeopardy [DATE] document revealed one hundred-eleven (111) residents (census of [DATE]) were reviewed for falls in the past three (3) months-date/time/root cause; interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit with signatures of nurses completing the audits. In addition, record review of Unsampled Resident C's individualized toileting program revealed it had been revised as a result of the audit on [DATE] with changes to reflect a time frame for toileting of 3:00 AM - 5:00 AM as the resident had fallen during those hours when attempting to self toilet. Interview with the DON on [DATE] at 10:00 AM revealed he was involved in the audit of all residents' charts who were in the facility on [DATE] to review all falls within the past three (3) months in regard-date/time/root cause, interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit. Interview with the Risk Manager, on [DATE] at 4:32 PM, revealed she was involved in the review of residents' falls for the past three (3) months that included the current census of one hundred and eleven (111) residents on [DATE] and the review covered the date/time/root cause, interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit. Interview with the Minimum Data Set nurse, on [DATE] at 3:44 PM, the Restorative/Wound Care Nurse, on [DATE] at 3:55 PM, two (2) Unit Managers on [DATE] at 4:45 PM, a Staff Nurse, on [DATE] at 5:05 PM, and the Staff Development Coordinator, on [DATE] at 5:30 PM, revealed they had all been involved in the audit of the facility residents on [DATE] to review all falls within the past three (3) months in regard-date/time/root cause, interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit. Record review of one resident's individualized toileting program revealed it had been revised as a result of the audit on [DATE] with changes to reflect a time frame for toileting of 3:00 AM - 5:00 AM as the resident has fallen during those hours when attempting to self toilet. 4. Review of the policy, Accident and Incidents, on [DATE] at 9:00 AM revealed it had been revised to include notification to the physician within thirty (30) minutes of a fall involving head injury or a fall which was not witnessed. Review of the policy, Falls Prevention, on [DATE] at 9:10 AM, revealed it had been revised to include the check of safety devices each shift to ensure they are in place and functioning properly. Interview with the Administrator and the DON, on [DATE] at 10:05 AM, revealed they had met with the Medical Director on [DATE] to review policies, procedures and practices for physician notification, root cause analysis of accidents, incidents and falls prevention, revision of care plans and the scheduled toileting program and they made revisions to the Falls Prevention and the Accident and Incidents policies. Observation, on [DATE] at 10:40 AM, revealed Resident #25 had an alarm on the wheelchair as care planned and on [DATE] at 1:00 PM, Resident #25 was seated in the wheelchair with an alarm on the wheelchair. Observation of Resident #27, on [DATE] at 8:15 AM and 1:25 PM, revealed an alarm on the resident's wheelchair. Review of the record for Resident #25 revealed the resident's alarm had been checked on day shift per facility policy and was functioning and review of Resident #27's record revealed the resident's alarm had been checked on the day shift per facility policy and was functioning. 5. Review, on [DATE] at 10:13 AM, of the content for an inservice to licensed nursing staff on [DATE] revealed the procedure for conducting neurological checks was reviewed by the Director of Nurses and Staff Development with the nurses and they were informed of additional pen lights (used during the neurological checks) being available in the facility on all of the crash carts. Review of two (2) medical supply company invoices on [DATE] revealed additional pen lights had been ordered by the Administrator for nurses to use during neurological checks. Observation of a neurological check performed by Licensed Practical Nurse (LPN) #4 on Resident #26, on [DATE] at 12:30 PM, revealed proper technique per standards of nursing practice and followed the facility's retraining for nurses on neurological checks. Interview with LPN #4, on [DATE] at 10:20 AM, revealed she had been retrained on neurological checks for residents with possible head injury during a training provided to all licensed nurses on [DATE] by the Staff Development Coordinator and she knew pen lights were available in the facility on the crash carts. 6. Interview with the Activity Director, on [DATE] at 3:50 PM, revealed she had been present on [DATE] in a Standards of Care meeting and had been involved in the review and revision of care plans for residents who had fallen. Interview with the MDS Coordinator, on [DATE] at 3:44 PM, revealed she was involved in the Standards of Care meetings weekly, on [DATE] and in the review or revision of care plans for residents who had fallen. 7. Interview and record review with the DON, on [DATE] at 2:19 PM, revealed he was provided training by the Administrator on [DATE] on physician/responsible party notification after a resident's fall. He revealed he and the Staff Development Coordinator began on [DATE] an all nursing staff training regarding the physician/responsible party notification after a resident's fall, and continued through [DATE]. A review of in-service training records on [DATE] revealed one hundred nineteen (119) staff had been trained by 9:30 PM on [DATE] as cross-referenced with the facility human resource department staff roster. The training also included: work order process; care plans; certified nursing assistant care sheets; proper use and types of alarms; the scheduled toileting program process/form to be used and proper completion of the form. Th

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure care plans were individualized based on resident assessments and failed to ensure resident care plans were revised with interventions that prevented additional falls after sustaining falls for five (5) of thirty-two (32) sampled residents. (Resident's #8, #13, #15, #17, and #20). (Refer to F323) Resident #20 had sustained a total of seven (7) falls from [DATE] through [DATE]. Review of the resident's Nursing Care Plan for falls, dated [DATE], revealed the pre-printed care plan interventions did not reflect the facility had provided direction to staff to increase Resident #20's supervision or provide assistive devices after Resident #20's falls. On [DATE] Resident #20 fell and sustained a hematoma to the head. The resident fell again on [DATE] and hit his/her head excerbating the injury received on [DATE]. The resident was transferred to the hospital after a decline in consciousness and subsequently expired on [DATE]. Resident #15's care plan was not revised with new interventions after the resident sustained [REDACTED]. Resident #13's care plan was not revised with new interventions after the resident was found crawling on the floor on [DATE] on three (3) separate occasions. Resident #17's care plan was not revised with new interventions after the resident sustained [REDACTED]. Resident #8's care plan was not revised after a fall on [DATE] with new interventions. The facility's failure to have an effective system in place for revising resident care plans to ensure safety after falls has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE]. The scope and severity was lowered to an "E" while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Comprehensive Care Plans, dated July, 2009, revealed all care plans would be reviewed and updated quarterly or as needed by the interdisciplinary team. 1. Review of the closed clinical record for Resident #20 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #20 also had a history of [REDACTED]. Review of Resident #20's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with Brief Interview for Mental Status and determined the resident scored an eight (8) out of fifteen (15) moderate cognitive impairment. The facility further assessed the resident as extensive assistance with two plus persons for bed mobility; transfers; ambulation; and, locomotion. The resident's balance was not steady and was only able to stabilize with staff assistance. In addition, the resident sustained [REDACTED]. Review of the CAT worksheet for Falls, dated [DATE], revealed the resident had impaired balance during transitions and required human assistance for transitions. The resident had a [DIAGNOSES REDACTED]. These factors all increase risk for falls. The resident was also noted wandering throughout the facility. Under the notes section revealed sensor alarms were being utilized to alert the staff should resident attempt to rise unassisted. Review of the comprehensive care plan for Resident #20, dated [DATE], revealed a potential for falls related to a history of falls, medication use, cognition and immobility. Interventions stated a sensor alarm to bed and chair as ordered; notify appropriate parties if fall occurs; give resident verbal reminders not to ambulate or transfer without assistance; properly fitting non-skid shoes for ambulation; and, environment free of clutter. Review of the Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident as not steady on his/her feet and required extensive assistance from staff to toilet, walk, and bathe. A Brief Interview for Mental Status (BIMS) was conducted during the assessment and the resident scored an eight (8) out of fifteen (15) indicating moderate cognitive impairment. On [DATE], Resident #20 was in the closet, looking for a change of clothing with a brief around the ankles wet with urine and feces on the buttocks. The door to the room was shut. The nurse startled the resident upon entry to the room and caused the resident to fall and hit his/her head on the room mates foot board. Resident #20 sustained a decline in consciousness and was transferred to the hospital where he/she expired on [DATE]. Record review revealed Resident #20 had sustained six (6) falls prior to the fall on [DATE]. However, review of the resident's Nursing Care Plan for falls, dated [DATE], revealed the pre-printed care plan interventions did not reflect the facility had provided direction to staff to increase Resident #20's supervision or provide assistive devices after Resident #20's six (6) fall episodes on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the Fall Scene Investigation report, dated [DATE], revealed the resident slipped and fell after trying to ambulate alone. The report revealed the Director of Nursing (DON), Administrator (ADM) and Risk Manager (RM) did not meet regarding the fall until [DATE] (nine days later) and made no recommendations to change or revise Resident #20's plan of care. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #20's fall was due to non-compliance with care and the resident was experiencing intermittent confusion. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #20 fell reaching for a trash can. The DON, ADM and RM met on [DATE] regarding the falls on [DATE] and [DATE] but the resident's care plan was not revised to address these falls. Review of the Fall Scene Investigation report, dated [DATE], revealed the DON, ADM and RM met on [DATE] regarding the fall on [DATE] and there was no evidence on the form that the DON or ADM had made any additional recommendations or provided direction to change the plan of care. Review of Resident #20's previous Fall Scene Investigation report, dated [DATE], revealed the resident fell at 5:30 AM, and was found by staff on the floor with the bed alarm not sounding. The resident sustained [REDACTED]. The report stated staff witnessed the resident trying to silence the bed alarm after attempting an unsafe transfer earlier in the shift. Further review of the Fall Scene Investigation report revealed it did not indicate nursing had increased resident supervision to monitor for bed alarm manipulation or unsafe transfers prior to the fall. Continued review of the Fall Scene Investigation report, dated [DATE], revealed the root cause of the fall was the resident had attempted an unsafe transfer and turned off the alarm. Previously in the shift the resident attempted an unsafe transfer and tried to figure out how to turn off the alarm. The DON, ADM and Risk Manager RM met regarding the fall on [DATE] and there was no evidence on the form that the DON or ADM had made recommendations or provided direction to change the plan of care. 2. Review of the clinical record for Resident #15 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Further review revealed Resident #15 had a history of [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the resident was not steady on his/her feet and needed extensive assistance from staff to toilet, walk, transfer and bathe. The MDS further revealed staff could not conduct a Brief Interview for Mental Status (BIMS) due to the resident having short-term and long-term memory problems which affected his/her ability to make decisions and follow cues. The facility determined the resident required supervision in daily decision making. Review of the Comprehensive Care Plan, dated [DATE], revealed a history of falls with potential for reoccurring falls related to medication use, cognition, immobility and advancing Dementia. Interventions, not dated, stated the staff was to notify appropriate parties if fall occurs; activity care plan for individual interests; sensor alarm; non-skid strips to bed side; verbal reminders not to ambulate or transfer without assistance; properly fitting non-skid soled shoes for ambulation; and, environment free of clutter. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 experienced a non-injury fall on [DATE] at 4:25 PM. The investigation report revealed the resident was trying to get up to go to the bathroom. Staff left blank the section of the investigation report titled Additional Care Plans/Care Sheet Updates. Review of Resident #15's Care Plan, dated [DATE], revealed the facility did not revise the plan of care after the fall. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 experienced a non-injury fall on [DATE] at 7:00 PM. The fall report stated the resident was attempting to self-ambulate out of the bathroom when the resident fell backward onto his/her buttocks. Staff entered a n/a (not applicable) in the section of the investigation report titled Additional Care Plans/Care Sheet Updates. Review of Resident #15's Care Plan, dated [DATE], revealed the facility did not revise the plan of care after the fall on [DATE] with interventions that addressed supervision or actions to meet the care needs of the resident. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 experienced a non-injury fall on [DATE] at 2:45 PM. The fall report stated staff had found the resident sitting on the floor in the resident's bedroom doorway without his/her wheel chair, walker, or alarms. Further review revealed the resident had a tab alarm to alert staff when rising. After the fall on [DATE], nursing staff ordered the tab alarm to be placed on the hand rail next to the toilet. No additional interventions were added to the Plan of Care for supervision of the resident while toileting or walking after the fall on [DATE]. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 fell on [DATE] at 3:20 AM. The staff reported the resident was getting up from the recliner in the common area to go to the toilet and landed face down on the floor. Resident #15 obtained a 0.5 cm laceration to the left eyebrow. The Additional Care Plans/Care Sheet Update section of the form stated staff would continue using alarms as ordered. Review of Resident #15's Care Plan, dated [DATE], revealed the facility did not revise the plan of care after the fall, on [DATE] with interventions that addressed supervision or actions to meet the care needs of the resident. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 fell on [DATE] at 9:15 AM. The fall report stated the resident was getting up to use the toilet. The resident received an abrasion to the mid upper back and a skin tear to the right elbow that was about 1.8 cm long. The resident was incontinent of urine at the time of the fall. The Additional Care Plans/Care Sheet Update part of the form was crossed through. Review of Resident #15's Care Plan, dated [DATE], revealed the care plan was not revised after the resident's fall on [DATE] to ensure the resident's toileting needs were met. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 fell on [DATE] at 10:55 AM. The fall report revealed Resident #15 was walking around the room, making the bed, and was also incontinent of urine at the time of the fall. The Additional Care Plan Update section of the form was crossed through. The Nurse's Notes for Resident #15, dated [DATE] at 10:55 AM, revealed a sensor alarm to the bed was found face down on the bed and was not sounding. Review of Resident #15's Care Plan, dated [DATE], revealed the staff did not revise the care plan after the resident's fall on [DATE] with interventions to increase supervision or that addressed toileting needs. Interview with the Risk Manager, on [DATE] at 9:30 AM, revealed the IDT had discussed leaving the resident alone on the toilet; however, the care plan was not revised after the meeting. 3. Review of the clinical record for Resident #13 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Comprehensive Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident triggered as at risk for falls and did not ambulate, but used a wheelchair for mobility. Review of the Quarterly MDS, dated [DATE], revealed Resident #13 required the assistance of one (1) staff member for transfers. Review of Resident #13's Comprehensive Care Plan, dated [DATE], revealed interventions for falls prevention included sensor alarm to bed and chairs as needed; mattress with raised edges; low bed with floor mats; however, it did not specify what the staff were to do when the resident crawled out the wheelchair onto the floor. The care plan stated that prior to the resident's admission to the facility he/she had a history of [REDACTED]. Interview, on [DATE] at 12:05 PM, with LPN # 5 revealed it was her understanding that prior to Resident #13's admission to the facility, the resident crawled from chairs/furniture in his/her home to the floor as a means of getting around, and at times, the resident had exhibited this behavior as a means of transfer/locomotion since he/she had been living at the facility. Review of Resident #13's nurses' notes, dated [DATE] at 4:40 AM, revealed on [DATE] at 12:30 AM, Resident #13 was found crawling on the floor mat beside his/her bed. The resident had defecated on the floor mat. Staff toileted the resident, and assisted him/her back to bed. At 4:40 AM, after the resident was transferred by staff via wheelchair to the Orchard Unit sitting area, the resident's chair alarm sounded and he/she was found crawling on the floor. Further review of the nurses' notes revealed on [DATE] at 7:00 AM, Resident #13 was again found on the floor of the unit's day room/sitting area. The resident was positioned on the floor between his/her wheelchair and another chair. The resident was assessed and a small laceration (,[DATE] centimeters) was found at the back of his/her head. Resident #13's physician was notified and the resident was transferred to a hospital emergency department for evaluation. Review of the comprehensive care plan for Resident #13, did not reveal new or additional interventions added or documented on the falls care plan after the resident had three (3) documented falls on [DATE] between 12:30 AM - 7:00 AM. Review, of the report of Resident #13's falls on [DATE], did not reveal new interventions were added under the Intervention to Prevent Further Falls/Ensure Safety section of the report. Instead, LPN #5 had written, continue with care plans currently in place. Interview, on [DATE] at 12:05 PM, with LPN #5 revealed the resident's tab alarm sounded both times when he/she left the wheelchair and was discovered on the floor of the dayroom on [DATE] at 4:40 AM and 7:00 AM, but LPN #5 further stated she did not think she updated the care plan after those falls. LPN #5 stated she thought the resident was care planned to be able to crawl from his/her wheelchair to the floor. Continued interview, on [DATE] at 12:05 PM, with LPN #5 revealed she thought Resident #13's care plan should have been updated to address the falls because it was not safe for the resident to crawl from a wheelchair to the floor. LPN #5 stated she could have met with the facility's Risk Management Nurse to decide on new or different interventions to protect the resident from further falls related to crawling from the wheelchair. Interview, on [DATE] at 2:40 PM, with the Unit Manager (UM) for the Orchard Unit, revealed Resident #13 was not care planned to crawl from one area to another on the Orchard Unit, such as from his/her wheelchair to the floor. The UM stated she had seen Resident #13 crawl out of his/her wheelchair, but further stated it was not safe for the resident to crawl out of the wheelchair. The Orchard UM stated Resident #13's falls care plan should have been updated after the resident fell two times on the floor of the Orchard Unit on [DATE]. The UM stated that after Resident #13's return from the hospital, he/she could have been evaluated by therapy to determine if any other safety interventions could have been appropriately implemented to protect the resident while seated in the wheelchair. 4. Review of the clinical record for Resident #17 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #17, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating cognitively intact. Review of the Comprehensive Care Plan, dated [DATE], revealed the potential for falls related to history of falls, medication use, immobility, Dementia, and incontinence. Interventions, not dated, stated a sensor alarm to bed and chair that was discontinued on [DATE] and a tab alarm to bed and chair was initiated on [DATE]; verbal reminders not ambulate or transfer with assistance; properly fitting non-skid soled shoes for ambulation; and, environment free of clutter. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #17 fell on [DATE] at 8:50 AM. The staff found Resident #17 on the floor in his/her room. The resident obtained a laceration to the forehead, along with skin tears to left forearm and right elbow. Resident #17 was sent to the emergency room for evaluation. The root cause portion of the document stated it appeared the resident fell asleep and fell out of the wheel chair head first, into the foot rail of the bed. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #17 experienced a non-injury fall on [DATE] at 5:45 PM. The investigation report indicated the staff found the resident on the floor in his/her room in front of his/her wheel chair. Review of the nurse's notes, dated [DATE] at 10:50 AM, revealed the alarm clip had slipped off the resident's shirt, preventing the alarm from sounding. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #17 experienced a non-injury fall, on [DATE] at 6:45 PM. The investigation forms revealed the resident was attempting to take shoes off when he/she slid out of the wheelchair. Review of the Nurse's Notes for Resident #17, dated [DATE] at 7:00 PM and [DATE] at 7:00 PM, stated the resident was observed sliding out of the wheelchair while attempting to remove his/her shoes and was educated to call for help when toileting or dressing. Review of Resident #17's Care Plan, dated [DATE], revealed the staff had not added new interventions to the falls section of the care plan after the resident fell on [DATE], [DATE], or on [DATE]. 5. Review of the clinical record for Resident #8 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) was conducted during the assessment and the resident scored an eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of the Comprehensive Care Plan, dated [DATE], revealed a potential for falls related to history of frequent falls, unsteady gait, medication use, immobility, and cognition deficit. Interventions, not dated, stated notify appropriate parties if falls occur; rear anti-tippers to wheel chair; anti-rollbars to wheel chair; mattress with raised edges; properly fitting non-skid sole shoes for ambulation; and, environment free of clutter. Review of the Nursing Notes, dated [DATE] and timed at 9:25 PM, revealed the nurse was standing outside Resident #8's room when she heard a loud sound and upon entering the resident's room she observed the resident sitting on the bathroom floor. The nursing notes stated the resident was brushing his/her teeth and the resident's legs became weak and the resident fell . Review of Resident #8's, Falls Nursing Care Plan, dated [DATE], revealed no revisions or updates were made after Resident #8's fall on [DATE] to promote safety and prevent additional falls. Review of Resident #8's Fall Scene Investigation Report, dated [DATE], revealed the root cause of the fall was the resident's legs became weak while standing. Nursing was to place the resident's name on the physicians list for review and to complete neuro-checks. The Summary of Meeting and Additional Care Plan Update sections were blank. Interview with the Advance Practitioner Registered Nurse (APRN) on, [DATE] at 2:15 PM, revealed she had not assessed the resident as of [DATE] in regards to the fall on [DATE]. The APRN said, according to her review of the physician's documentation in the medical record, Resident #8's physician had not performed an assessment to determine the cause of the fall as of [DATE]. She stated the physician would assess medication for potential causes of falls and look at the resident's [DIAGNOSES REDACTED]. Interview with the Risk Manager (RM), on [DATE] at 10:30 AM, revealed the root cause of Resident #8's fall was the resident's legs became weak while standing. The RM stated she did not complete her documentation under the Summary of Meeting where she would have met with the Administrator and the Director of Nursing to discuss the fall. She stated if the area under Additional Care Plan Update sections were blank there were none to document. Interview with the Director of Nursing on, [DATE] at 3:00 PM, revealed he had not provided direction to the Risk Manager regarding adding additional falls prevention interventions to Resident #8's plan of care. He stated he was not aware the physician had not assessed the resident since the fall on [DATE]. He stated he did not perform chart audits to determine if interventions were completed. Interview with the Risk Manager (RM), on [DATE] at 9:35 AM, revealed her responsibility was to ensure follow-up occurred after each resident fall, complete the documentation under the Falls Team Notes section of the Fall Scene Investigation report and report falls data/information to the Safety and Quality Assurance Committees. She stated it was nursing's responsibility to revise the care plan after a fall. She stated after each fall she reviewed the Fall Scene Investigation form the nurses completed to ensure the care plan was revised after a fall, if indicated; however, did not actually check the care plan for the revision. She stated she would try and meet with the Director of Nursing and the Administrator at least every other week to discuss the findings of the fall but this was not a set time frame. Interview with the Director of Nursing on, [DATE] at 3:00 PM, revealed if a resident experienced a fall it was discussed in the morning meeting the day after the fall occurred. He stated the Administrator, Risk Manager and himself would meet to review a resident's fall. He stated he did not keep any record of the meetings and did not remember if he provided any direction to staff regarding the implementation of additional interventions for Resident #20. He stated it was his expectation that the nursing staff revise resident care plans after incidents occur. However, interview with LPN #8, on [DATE] at 9:55 AM, revealed the revision of the care plan after falls was to be completed by the RM. Interview with the Unit Manager, on [DATE] at 8:30 AM, revealed she was not sure about what interventions would be used to revise the care plan. Interview with the Administrator on, [DATE] at 5:25 PM, revealed he did not provide direction to the Director of Nursing or the Risk Manager regarding the care plan revisions for falls. Review of the Allegation of Compliance (AOC) revealed the facility implemented the following immediate steps to remove the Immediate Jeopardy: 1. The Medical Director was notified of Immediate Jeopardy and incidents causing the Immediate Jeopardy on Thursday [DATE]. 2. A representative of the Governing Body provided the Administrator guidance and education on physician and family notification, supervision and investigation of falls, care plan revisions and scheduled toileting programs on [DATE] and [DATE]. 3. Licensed nurses (DON, Staff Development Coordinator, Risk Care Manager, Restorative/Wound Care Nurse, Minimum Data Set Nurse, House Supervisor, two (2) Unit Managers and a Staff Nurse) completed an audit on [DATE] for the one hundred eleven (111) residents currently in the facility. This included thirty (30) residents who had a fall in the past three (3) months, and eighty-one (81) residents who had no fall within the past three (3) months. The audit included a review of the fall event document for those who had fallen for root cause of the fall, interventions added to the care plans at the time of the fall, times of scheduled toileting program (if any), alarms utilized, care plans, notifications made to the attending physician and resident's responsible party and interventions added after the audit was completed. An action taken as a result of the audit included update/revision to care plans for eleven (11) residents that included reachers; toileting in early morning hours; sensor pads; mattresses; and, non-skid strips to the floor. In addition, one resident's toileting program was addressed as a result of the [DATE] audit with changes to the timing of the toileting program based on his/her individualized needs. 4. The Medical Director met with the Director of Nursing (DON) on [DATE] to review policies, procedures and practices for physician notification, root cause analysis of accidents, incidents and falls prevention, revision of care plans and the scheduled toileting program. Revisions were made to the policy, Accident and Incidents, for physician and responsible party notification to include notification to the physician within thirty (30) minutes of a fall involving head injury or a fall which was not witnessed. Revision was made to the policy, Falls Prevention, to check safety devices each shift to ensure they are in place and functioning properly. 5. The procedure for conducting neurological checks was reviewed by the DON and the Staff Development Coordinator and all licensed nurses provided education on that process on [DATE] through [DATE]. The DON and the Staff Development Coordinator conducted the inservice training on neurological checks and additional pen lights (used to conduct the neurological checks) were ordered by the DON on [DATE]. 6. The MDS Coordinator, MDS Nurse, DON and Risk Manager are responsible for ensuring care plans are completed/revised in a timely/accurate manner. The care plans of residents who have fallen would be reviewed weekly in a Standards of Care meeting led by the MDS Nurse and the MDS Coordinator. In attendance at that meeting are the Dietary Manager, Risk Manager, Social Services Representative and the Activity Director. A report would be generated in that meeting of all falls, the review/revision of the residents' care plans and any actions taken to address concerns which would include staff education, staff discipline and care plan revisions to the Quality Assessment and Assurance Committee monthly from [DATE] - [DATE]. 7. The DON and the Staff Development Coordinator were provided training by the Administrator on [DATE] on physician and responsible party notification. The DON and the Staff Development Coordinator initiated all licensed nurses' and Certified Nursing Assistants' (CNA) training on [DATE] and continued that training through [DATE]. A total of one hundred nineteen (119) staff had been trained by 9:30 PM on [DATE] with one (1) remaining staff notified they must receive training by their supervisor prior to returning to work. The training to all licensed nurses and certified nursing assistants included: work order process, care plans, certified nursing assistant care sheets, proper use and types of alarms, the scheduled toileting program process/form to be used and proper completion of the form. The licensed nurses received training on: falls and proper process for notification of the resident's physician, the responsible party, the neurological check process, the proper completion of the Event Report Form, review/revision of care plans, root cause analysis process, policy and procedure on Accidents and Incidents, policy on Falls Prevention, Neurological check protocol form and the form used for the Scheduled Toileting Program. 8. The Administrator provided training to the Director of Nursing, the Risk Manager and therapy staff on [DATE] and [DATE] regarding the IJ, policy and procedure revisions, processes of Falls Committee Meeting, quality assessment and assurance committee role to ensure compliance and develop further actions to be taken. 9. Three (3) notifications of residents' who fell prior to [DATE] was made to the attending physicians and responsible party on [DATE] with one (1) physician and the responsible party notification of a fall which occurred on [DATE]. 10. A Falls Committee was initiated [DATE] to review fall interventions, to review reviewed/revised care plans and to complete root cause analysis for falls during the meeting. The Falls Committee is comprised of the Administrator, the DON, a MDS Nurse, Social Worker, Risk Care Manager, Restorative/Wound Care Nurse and the Rehabilitation Services Manager and meets Monday-Friday. 11. The DON provided training to the Restorative/Wound Care Nurse on [DATE], [DATE] and [DATE] addressing the facility's scheduled toileting program, the toileting program as it relates to falls, review of the four day bowel and bladder assessment process to note patterns and trends to develop an individualized scheduled toileting program for the resident, the process of documentation on the toileting program form and the creation of an audit tool to audit the clinical documentation relative to the toileting program, monitor for patterns and trends of the toileting program and a system to report findings of the audits to the Quality Assessment and Assurance Committee. 12. The Restorative/Wound Care Nurse would audit the toileting program using the Scheduled Toileting Audit tool. The toileting program documentation was to ensure accuracy and comp

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure adequate supervision and assistive devices to prevent accidents and to ensure the residents' environment was free of accident hazards. The facility failed to determine the root cause of resident falls and failed to assess its fall prevention processes to determine if they were implemented and effective in promoting a safe environment for six (6) of thirty-two (32) sampled residents, (Residents #8, #13, #15, #16, #17, and #20). (Refer to F157, F280 and F315) On [DATE] at 5:30 AM, Resident #20 sustained a fall with injury. The resident sustained [REDACTED]. The facility did not complete a root cause analysis as to the cause of the fall. Resident #20 sustained a second fall on [DATE] at 11:55 PM, which resulted in a head injury and required transfer to the hospital for treatment where the resident subsequently expired on [DATE]. Record review and interview revealed Resident #20 has sustained a total of seven (7) falls from [DATE] through [DATE] with no evidence the facility had revised interventions to prevent further falls. On [DATE] at 3:20 AM, Resident #15 had a fall and sustained a laceration to the left eyebrow. The facility failed to complete a root cause analysis and on [DATE] at 11:20 AM, Resident #15 fell again and sustained an injury to the right shoulder and hit his/her head. Resident #15 then fell on [DATE] at 9:15 AM and received an abrasion to the mid upper back and a skin tear to the right elbow. On [DATE], Resident #13 was found crawling on the floor mat beside the bed at 12:30 AM; found at 4:40 AM, crawling on the floor; and, again at 7:10 AM, the resident was found crawling on the floor with a small laceration to the back of the head. On [DATE] the resident sustained [REDACTED]. The facility applied steri-strips and a dry dressing to cover. Resident #17 sustained three (3) falls occurring on [DATE], [DATE] and [DATE]. The resident required stitches with the [DATE] fall. The tab alarm was not attached to the resident during the [DATE] falls. On [DATE] at 9:25 PM, Resident #8 sustained a fall while in the bathroom and staff found the resident on the floor. The facility did not complete a root cause analysis to determined the resident's need for additional assistance. Resident #16 was found on [DATE] at 2:45 AM with his/her body half on the bed, and half on the floor. The nurse's note revealed the resident had no apparent injuries, but neurological (neuro) checks were initiated by the facility's protocol. There was no root cause analysis completed for the fall. In addition, the facility failed to ensure one (1) of sixty-one (61) resident rooms (Room #2), with a missing electrical plate allowing residents access to the wires, was repaired to prevent potential injury, and failed to ensure wheelchair arm pads were replaced to prevent potential skin tears for ten (10) of seventy-eight (78) wheelchairs. The facility's failure to have an effective system in place to determine the root cause of falls and assess prevention processes to determined if they were implemented and effective in promoting a safe environment for residents at risk has caused or is likely to cause serious injury, harm, impairment or death to resident. The Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE]. The scope and severity was lowered to an "E" while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Accidents and Incidents, dated [DATE], revealed it was the policy of the facility to have a safe and healthy environment. Therefore, all accidents or incidents occurring on facility premises must be reported and investigated. For reporting purposes, an accident/incident was defined as an occurrence with the potential of injury, illness, altercation, etc., or any single event that resulted in personal injury or illness to a resident. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and an Event Documentation Form must be completed on the shift the accident or incident occurred. A falls scene investigation would be completed for residents with witnessed or suspected falls. The Staff/Charge Nurse must be informed of all accidents or incidents so that medical attention could be provided. Residents hitting their head when falling or any un-witnessed falls would be monitored by routine neuro-check protocol; notify the Medical Director or the victim's attending physician and inform him or her of the accident or incident; make an entry in the resident's chart each time an attempt was made to contact the physician; provide care and transfer the resident, if necessary, as ordered by the physician or at the nurse's discretion; and, contact the resident's representative of the accident/incident or injury with 24 hours or immediately in emergency situations. The Director of Nursing would review all accidents or incidents discussing any concerns with the nurse responsible for the care. The Risk Manager or designee would be responsible for reviewing and analyzing all Event Documentation Forms for trending purposes and modifications to a resident's plan of care and forward all reports to the Administrator for review. Residents noted with multiple incidents would be reviewed as indicated at Resident Safety Committee to evaluate the plan of care. Nursing Services would be responsible for analyzing previous month's data for the Quality Assurance Committee. 1. Review of the closed clinical record for Resident #20 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #20 had a history of [REDACTED]. A Falls Risk Assessment, completed on [DATE], revealed the resident had one-two falls in the past three months; the resident was chair bound; vision was poor; and, gait/balance the resident was unable to perform this function. Review of the initial care plan, dated [DATE], revealed the staff were to keep the call light in reach; encourage use of the call light; orient the resident to the room; sensor alarm; appropriate foot wear; Physical Therapy evaluation; and transfer utilizing one person. Review of Resident #20's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with Brief Interview for Mental Status and determined the resident scored an eight (8) out of fifteen (15) moderate cognitive impairment. The facility further assessed the resident as extensive assistance with two plus persons for bed mobility; transfers; ambulation; and, locomotion. The resident's balance was not steady and was only able to stabilize with staff assistance. In addition, the resident sustained [REDACTED]. Review of the CAT worksheet for Falls, dated [DATE], revealed the resident had impaired balance during transitions and required human assistance for transitions. The resident had a [DIAGNOSES REDACTED]. These factors all increase risk for falls. The resident was also noted wandering throughout the facility. Under the notes section revealed sensor alarms were being utilized to alert the staff should resident attempt to rise unassisted. Review of the comprehensive care plan, dated [DATE], revealed a potential for falls related to a history of falls, medication use, cognition and immobility. Interventions included sensor alarm to bed and chair; notify appropriate parties if falls occur; verbal reminders to not ambulate or transfer without assistance; appropriate foot wear; and, environment free of clutter. Continued review of the comprehensive care plan, dated [DATE], revealed interventions added on [DATE] non-skid liner to wheelchair; [DATE] antitipper to back of wheelchair; and on [DATE] tab alarm with pin and clip to toilet; pommel cushion to wheelchair; and padding to wheelchair sides. Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status and determined the resident scored an eight (8) out of fifteen (15) moderate cognitive impairment. The facility further assessed the resident as requiring one person assist with locomotion and walking balance was only able to stabilize with staff assistance. The assessment further revealed the resident had prior falls. Review of Resident #20's toileting documentation revealed there was no completed assessment of urinary frequency, incontinence or continent episodes documented to determine if the toileting program was meeting the need of the resident or the goal to decrease the number of incontinent episodes. This resident sustained [REDACTED]. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #20 sustained a fall on [DATE] at 11:55 PM, and the physician was not notified of the fall until eight and one-half (8.5) hours later at 8:30 AM on [DATE]. In addition, the facility did not notify the resident's responsible party of the fall on [DATE] until 8:40 AM on [DATE] when preparations were underway to transfer the resident to the emergency room . Review of the Nursing Notes for Resident #20, dated [DATE] and timed at 11:55 AM, revealed Resident #20's door was found closed and the resident's bed alarm was heard faintly sounding from outside the door. When the nurse opened the door the resident was found standing behind the door and inside the closet. The nurse documented that opening the door had startled the resident and the resident tried to grab the door while it was opening and lost his/her balance, fell and hit his/her head on the foot board of the roommate's bed. The nurse noted Resident #20's brief was down around the ankles, and wet with urine. There was feces on the resident's buttocks. Nursing noted neuro-checks were started after the fall. However, review of the facility's Neurocheck Protocol document, dated [DATE], revealed the neuro-check block, timed at 6:55 AM, and the last one completed while the resident was in the facility, had a check mark in the box indicating findings were within normal limits. There was no documented evidence neuro-checks were completed after the [DATE] fall. Interview with Licensed Practical Nurse (LPN) #10, on [DATE] at 2:35 PM, regarding Resident #20's fall on [DATE], revealed she was in the hall when she heard a faint alarm sounding from inside Resident #20's room. She stated when she poked her head in the door, she startled Resident #20, causing him/her to fall and graze the back of the resident's head on the foot board of the bed. She stated she found the resident with feces on their bottom and a wet brief down around his/her ankles. She stated she discussed the incident with another LPN on duty to determine if the physician should be notified and the decision was made to wait until later in the morning when the physician was in the building to notify him of the fall. LPN#10 stated the neuro-checks were within normal limits. However, there was no documented evidence the neuro-checks were completed. Interview with Certified Nursing Assistant (CNA) #3, on [DATE] at 10:55 AM, revealed CNA #3 and CNA #2 checked on Resident #20 around 6:30 AM on [DATE], during change of shift rounds, and found the resident breathing differently. She stated the resident's face was bruised and the bruising extended down the neck to the shoulder. The CNA stated the resident had the largest hematoma (localized swelling filled with blood caused by a break in the wall of a blood vessel) to the forehead she had ever seen; it protruded out about one to two inches. She stated she nudged the resident to wake him/her to try and see if he/she wanted to get up for breakfast. The CNA stated the resident did not seem like him/her self and she had not received information in report that the resident had experienced a change in condition. CNA #3 stated this was not reported to nurse at that time. She stated she just kept an eye on the resident and came back around 7:45 to 7:50 AM to deliver the breakfast tray. She stated again the resident still did not seem right and was lifeless. CNA #3 stated she reported this to the nurse and the nurse came to assess the resident. Interview with CNA #2, on [DATE] at 11:10 AM, revealed she and CNA #3 went into Resident #20's room around 6:00 to 6:30 AM to get the resident cleaned up. CNA #2 said Resident #20 had bruising to the face, neck and shoulder and the resident complained about his/her face hurting so she did not wash it. She stated Resident #20 was squinting the left eye and complained of eye pain. She stated she left and came back about an hour and half (1.5) later, during breakfast tray delivery, to check on the resident and found the resident lifeless and unresponsive. She stated she was told in report the resident had fallen during the night, but no information was provided that indicated the resident had experienced a decline or was expected to pass soon. She stated she informed the nurse and the nurse came and assessed the resident. The CNA stated she was not aware the resident was on blood thinning medication. She stated that type of information was important to know because of the potential for bleeding if the resident experienced an injury. Interview with the Unit Manager, on [DATE] at 11:20 AM, and review of the Nursing Notes, dated [DATE] and timed at 8:25 AM, revealed the Unit Manager was called to Resident #20's room by an aide and the resident was found unresponsive to touch and verbal stimuli. She also noted a dried red tinged substance to the resident's lower lip and he/she was gurgling with wet lung sounds. She contacted the physician, who was in the building, and received an order to send the resident to the emergency room . Review of Resident #20's emergency room record, dated [DATE] and timed at 9:51 AM, revealed Resident #20's eyes were assessed upon admission and the findings revealed the left pupil was dilated (indicating neurological changes). An X-ray of the brain was ordered and the results were communicated to the emergency room physician at 10:25 AM and revealed a large brain bleed. Continued review of Resident #20's hospital record revealed the Physician's clinical report, dated [DATE] and timed at 10:27 AM, stated Resident #20's History of Present Illness and Chief Complaint was a changed mental status: "this started yesterday and was still present. It was abrupt in onset (since last night's fall). The patient was found unresponsive. (Via daughter: Patient fell 6 days ago and again last night. The first fall resulted in a contusion above the left eye, and it has been worsening ever since)". The physician documented a Final [DIAGNOSES REDACTED]. Continued review of the Physician's documentation revealed the care provider reviewed Resident #20's test results with the family and counseled them regarding patient's critical condition and poor prognosis for survival. The family requested comfort measures only. The resident expired 20 hours later at 6:00 AM on [DATE]. Interview with Resident #20's Responsible Party (RP), on [DATE] at 4:05 PM, revealed the facility did not contact them at the time of Resident #20's fall; it was not until the facility was in the process of transferring the resident to the emergency department were they notified of the fall. The RP stated the resident was relatively healthy for a ninety year old. RP said the resident had memory problems, history of falls, high blood pressure, history of blood clots in the leg, and arthritis. The RP stated the resident had a weak bladder causing frequent toileting, a bad knee and could not stand for long periods. The RP continued to say the resident was not experiencing any organ failure or decline and found it concerning that the resident was fine one day and unresponsive the next day. Further review of Resident #20's closed clinical record revealed the resident had fallen on [DATE] and sustained a head injury. Review of Resident #20's previous Fall Scene Investigation report, dated [DATE], revealed the resident fell at 5:30 AM and was found by staff on the floor with the bed alarm not sounding. The resident sustained [REDACTED]. The report stated staff witnessed the resident trying to silence the bed alarm after attempting an unsafe transfer earlier in the shift. Further review of documentation did not indicate whether nursing had increased resident supervision, to monitor for bed alarm manipulation or unsafe transfers prior to the fall. Continued review of the nursing documentation revealed Resident #20's physician was not notified of the fall with injury on [DATE] until 9:00 AM, three and half (3.5) hours later. Telephone interview with CNA #9, on [DATE] at 2:05 PM, regarding Resident #20's fall on [DATE], revealed she found the resident behind the door in his/her room. She stated no alarm was sounding to alert staff the resident was out of bed when she entered the resident's room. She stated it appeared the resident was trying to get into the closet, fell against the closet door, and sustained a goose egg injury to the forehead. She stated by the next day the bump on Resident 20's forehead had swollen tremendously and was purple in color. Telephone Interview with LPN #12, on [DATE] at 9:00 AM, regarding Resident #20's fall on [DATE], revealed she heard two CNAs yelling for assistance from Resident #20's room. She stated the resident was found in the floor behind the closed bedroom door by the closet door. She stated there was no alarm sounding at the time the resident was found. The LPN stated the resident was seen earlier in the shift fiddling with the alarm box. She stated the resident was assessed and found to have a hematoma to the left side of the forehead and right thumb. Further review of the Fall Scene Investigation report, dated [DATE], revealed the root cause of the fall was resident attempted unsafe transfer and turned off alarm. Previously in the shift the resident attempted an unsafe transfer and tried to figure out how to turn off the alarm. The Director of Nursing (DON), Administrator (ADM) and Risk Manager (RM) met regarding the fall on [DATE] and there was no documented evidence on the form that the DON or Administrator had made recommendations or provided direction to change the plan of care. Continued interview with Resident #20's Responsible Party (RP), on [DATE] at 4:05 PM, revealed the resident had fallen on [DATE] and had hit their head and sustained a hematoma to the forehead and bruise to the hand. The RP stated the resident was on blood thinning medication for the history of a blood clot in the leg, and this caused the increased bruising seen on the resident's face, neck and shoulder, after the fall on [DATE]. The RP stated they expected the facility to provide adequate supervision to prevent falls; however, the facility did not increase monitoring or rounding on the resident. Interview with the Risk Manager (RM), on [DATE] at 10:10 AM, revealed the root cause of Resident #20's fall on [DATE] was the resident attempted an unsafe transfer and turned off the bed alarm. She stated Resident #20 was on the facility toileting program; however, she had not reviewed the toileting program to determine if Resident #20's was effective and individualized or was the potential root cause for the resident's last two (2) falls. She stated she met with the DON and Administrator, to discuss the [DATE] and [DATE] falls on [DATE] (three days after Resident #20 passed). Telephone interview with the Medical Director, on [DATE] at 2:30 PM, revealed he was contacted by the DON on [DATE] regarding the Immediate Jeopardy. The Medical Director stated the facility had not done the right things in regard to the fall of Resident #20. Continued review of Resident #20's Fall Scene Investigation reports, revealed Resident #20 had sustained five (5) falls prior to the two (2) falls in December, 2014. The falls occurred on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the Fall Scene Investigation report, dated [DATE], revealed the root cause of Resident #20's fall was he/she slid out of the wheelchair with no injury. Review of Fall Scene Investigation report, dated [DATE], revealed the root cause of the fall was resident slipped and fell , next to the bed, while walking unassisted with no injury. However, there were no recommendations for care plan revisions written under the heading Additional Care Plan/Care Sheet Updates for the fall on [DATE] or [DATE]. In addition, the fall on [DATE] was not review by the DON, Administrator and RM until twenty (20) days later on [DATE]. The fall on [DATE] was not reviewed by the DON, Administrator and RM until nine (9) days after the fall on [DATE]. Further review of Resident #20's plan of care revealed a non-skid liner to the wheelchair was added to the wheelchair on [DATE], seventeen (17) days after the fall. Review of the Fall Scene Investigation report, dated [DATE], revealed the root cause of Resident #20's fall stated he/she was non-compliant with care and was experiencing intermittent confusion. The resident received no injury from the fall. The Fall Scene Investigation report, dated [DATE], revealed the root cause of Resident #20's fall stated the resident was reaching for a trash can. The fall did not result in any injury. The DON, Administrator and RM met on [DATE] regarding the falls on [DATE] and [DATE] and no recommendations for additional changes to the plan of care were documented as given by the DON or Administrator. Further review of Resident #20's plan of care revealed there was no revision to the interventions related to these two (2) falls. Review of the Fall Scene Investigation report, dated [DATE], revealed the root cause of the fall was it appeared the resident was ambulating from the toilet to the wheelchair unassisted, slipped and fell without injury. The DON, Administrator and RM met regarding the fall on [DATE] and there was no documented evidence on the form that the DON or Administrator had made recommendations or provided direction to change the plan of care. Further review of Resident #20's plan of care revealed a tab alarm pin/clip was added to the care plan on [DATE] to sit on the bar next to the toilet. Interview with LPN #5, on [DATE] at 9:20 AM, revealed she had placed Resident #20 on the toilet on [DATE], and left the resident unsupervised while she was completing tasks out in the resident's room. LPN #5 stated the resident was at high risk for falls, but believed it was safe to leave the resident unsupervised on the toilet. She stated she heard the resident fall and went to the bathroom to find the resident sitting crossed legged on the floor in front of the toilet. She stated the resident had a tab alarm to the bed and chair already and after the fall it was decided the alarm box would be placed on the hand rail next to the toilet. The LPN said that if the resident was left unsupervised again while toileting, it would alarm and notify staff the resident had raised from the toilet. She stated all staff know to supervise residents for safety, and that was done by rounding, which was done every two hours by the nursing assistants when they toileted and turned the residents. The LPN stated she did not provide additional direction to staff regarding increasing supervision of Resident #20 after the fall on [DATE]. She stated increased supervision was usually done only when a resident was exit seeking. Interview with the Risk Manager (RM), on [DATE] at 10:10 AM, revealed the determination of the root cause and interventions to prevent another fall was made by determining what the resident was doing at the time. She stated the root cause of an incident was not looked at in the manner that determined what facility systems or processes were not working properly. Interview with the Director of Nursing, on [DATE] at 3:00 PM, revealed he didn't remember if he provided any direction to the RM regarding implementing additional interventions for Resident #20. 2. Review of the clinical record for Resident #15 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) for Resident #15, dated [DATE], revealed the facility was unable to assess Resident #15 utilizing the Brief Interview for Mental Status (BIMS) due to the resident was rarely/never understood. Review of the Falls care plan, dated [DATE], revealed a history of falls with potential for reoccuring falls related to medication use, cognition, immobility; and advancing Dementia. Interventions for the Falls care plan, not dated, revealed the staff was to notify the appropriate parties if a fall occured; see activity plan for individual interests; sensor alarm; non-skid strips to bed side; verbal reminders to not ambulate or transfer without assistance; properly fitting non-skid soled shoes for ambulation; and, clutter free environment. Review of Resident #15's medical record revealed the resident had fall episodes documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the Fall Scene Investigation report, dated [DATE], revealed Resident #15 fell on [DATE] at 4:25 PM. The staff reported witnessing the resident fall in the common area. The investigation report further revealed the resident had stated he/she was trying to get up to go to the bathroom. The resident did not obtain any injuries from this fall. The facility staff identified the root cause of this fall that the resident's foot slid when he/she was getting out of a recliner. The staff left blank the section of the investigation report titled Additional Care Plans/Care Sheet Updates. Review of the care plan revealed no changes, that were dated, were made to the care plan after the fall on [DATE]. Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell on [DATE] at 7:00 PM. The fall report stated the resident was attempting to self-ambulate out of the bathroom in the resident room when he/she fell backward onto his/her buttocks. The nurse noted no injuries on this investigation. As the root cause, staff documented the resident was trying to get out of the bathroom. Staff entered n/a (not applicable) in the section of the investigation report titled Additional Care Plans/Care Sheet Updates. There were no changes, that were dated, added to the care plan after the fall on [DATE]. Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell on [DATE] at 2:45 PM. The fall report stated staff had found the resident sitting on the floor in the resident bathroom doorway without his/her wheel chair, walker, or alarms. The nurse noted no injuries on this Fall Scene Investigation report. As the root cause, staff documented the resident had an unsteady gait. The only notation found under interventions was on [DATE] "ER followup fall-slipped to floor unwitnessed found at bathroom door, no injury". Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell , on [DATE] at 3:20 AM. The staff reported the resident was getting up from the recliner in the common area to go the toilet when the fall occurred. The resident fell face down onto the floor from the recliner. The resident had taken shoes off while sleeping in the recliner. The resident obtained a 0.5 cm laceration to the left eyebrow. The additional care plan section of the form stated staff to continue using alarms as ordered. The following notation was listed under interventions on [DATE] "anti-rear tippers to wheelchair; and, anti-roll backs to wheelchair". However, the resident fell from a recliner and had no falls from the wheelchair. Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell on [DATE] at 11:20 PM. The fall report stated another resident reported to staff that he/she had heard someone fall. Staff went to Resident #15's room and found the resident attempting to get back into the bed. The resident had been incontinent of urine. The report further stated the resident had removed the sensor alarm from his/her bed and had placed it on the bedside table. The staff put an alarm in place. The resident hit his/her head and complained of pain in his/her right shoulder. The staff completed the additional care plan section of the form on [DATE] and indicated the facility would provide the resident with a mattress with raised edges to assist the resident to identify the edge of the bed. However, no interventions were put in place to address toileting needs or the removal of the sensor alarm from the bed. There were no changes made to the falls care plan after the [DATE] fall. Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell on [DATE] at 9:15 AM. The fall report stated the resident had stated he/she was getting up to use the toilet. The resident had been attempting to ambulate unattended in his/her room at the time of the fall. The resident received an abrasion on the mid upper back and a skin tear to the right elbow about 1.8 cm long. The resident was incontinent of urine at the time of the fall. The Additional Care Plan Update section of the form was crossed through. There were no changes made to the falls care plan after the [DATE] fall. Review of the Fall Scene Investigation, dated [DATE], revealed Resident #15 fell on [DATE] at 10:55 AM. The fall report revealed the resident had stated he/she was making the bed at the time of the fall. The resident had been attempting to ambulate unattended in his/her room and was incontinent of urine at the time of the fall. The Additional Care Plan Update section of the form was crossed through. There were no changes made to the falls care plan after the [DATE] fall. Interview with the DON, on [DATE] at 3:00 PM, revealed it was important to determine the root cause of incidents to ensure the appropriate corrective actions were put in place. He stated he had not provided any direction to staff to implement additional interventions for Resident #15. 3. Review of the clinical record for Resident #13 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Comprehensive Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident utilizing the Brief Interview for Mental Status (BIMS) with a BIMS score of 9. The assessment further revealed the resident triggered at risk for falls due to a history of falls and did not ambulate, but used a wheelchair for mobility. Review of Resident #13's Comprehensive Care Plan, dated [DATE], revealed that prior to the resident's admission to the f

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure a toileting program was implemented, monitored and revised to meet the residents' individual incontinent needs for two (2) of thirty-two (32) sampled residents (Resident's #15 and #20). Review of Resident #20's toileting documentation revealed there was no completed assessment of urinary frequency, incontinence or continent episodes documented to determine if the toileting program was meeting the need of the resident or the goal to decrease the number of incontinent episodes. This resident sustained [REDACTED]. On [DATE] the resident was ambulating from the toilet to the wheelchair when they fell hit his/her head. On [DATE] the resident was found in the closet trying to change his/her clothing, the brief was around the ankles wet with urine and feces was found on the resident's buttocks. The resident fell and hit their head on the room mates foot board and sustained a hematoma. The resident was transferred to the hospital for evaluation and expired on [DATE]. Review of Resident #15's toileting program revealed inconsistent documentation of the program and the resident sustained [REDACTED]. On [DATE] the resident was taking self to the bathroom and fell receiving a laceration to left eyebrow. On [DATE] the resident was incontinent and fell with pain in the right shoulder. On [DATE] the resident was taking self to the bathroom and fell sustaining an abrasion to the back and a skin tear to the elbow. The facility's failure to have an effective system in place for implementing, monitoring and revising the toileting programs for residents has caused or is likely to cause serious injury, harm, impairment or death to resident. The Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE]. The scope and severity was lowered to a "D" while the facility monitors the implementation of the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the a policy titles Bowel and Bladder and provided by the facility as the toileting program policy, dated [DATE], revealed every resident would be assessed and maintained at their highest level of continence. The toileting program would be individualized specific to a resident's incontinent pattern. The program would be implemented and noted on the plan of care. 1. Review of the closed clinical record for Resident #20 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #20 also had a history of [REDACTED]. Review of Resident #20's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident as not steady on his/her feet and requiring extensive assistance from staff to toilet, walk, and bathe. The MDS assessed Resident #20 as frequently incontinent of urine and was currently on a urinary toileting program. The facility conducted a Brief Interview for Mental Status (BIMS) during the assessment and the resident scored an eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #20's initial Plan of Care for Scheduled Toileting, dated [DATE] and the comprehensive care plan dated [DATE], revealed the goal was for the resident to have decreased episodes of incontinence. Interventions listed included; encourage resident to use the toilet in accordance with the program; evaluate the program quarterly and as needed; and, encourage the resident to request staff assistance with toileting at times other than scheduled toileting times. Review of the Behavioral Program form, dated [DATE], revealed Resident #20 was placed on a scheduled toileting program with interventions to toilet at regular intervals that matched elimination patterns identified. However, the Four (4) Day Bowel and Bladder assessment form, used to determine Resident #20's elimination patterns, dated [DATE], revealed no documentation the resident was toileted, found wet or dry for an eight (8) hour time-frame, on [DATE] from 5:00 AM to 1:00 PM, and for a twenty-two (22) hour time-frame on [DATE] from 2:00 AM until 11:00 PM. Again on [DATE], there was no documentation for a fourteen (14) hour time-frame from midnight till 2:00 PM. Review of the Scheduled Toileting Program plans, dated [DATE] through [DATE], revealed staff was to document continent episodes on the form under headings labeled: Toilet as needed during the night, with morning care, after breakfast, after lunch; between 3:00 PM and 5:00 PM, after supper, at bedtime; and, between 10:00 PM and 12:00 PM. On the bottom portion of the form the staff was to document incontinent episodes every two hours. Continued review of the Scheduled Toileting program forms revealed numerous blanks, indicating staff did not document continent and incontinent episodes as required each month. Continued review of the documents revealed no revisions were made to Resident #20's scheduled toileting time-frames to indicate the staff was performing toileting at the time the resident would mostly likely need to toilet. Review of the Restorative Monthly Assessment form, dated [DATE], revealed staff documented the resident continued to frequently dribble urine and had a decrease in ambulation ability due to knee pain. However, there was no documented assessment of urinary frequency, incontinence or continent episodes documented on the form to determine if the program was meeting the needs of the resident or the goal to decrease the number of incontinent episodes. Review of the Restorative Monthly Assessment form, dated [DATE], revealed staff documented Resident #20 had a significant decline in ambulation with complaints of bilateral leg pain and the resident remained on the scheduled toileting to decrease wetness along with unsafe transfers. However, there was no documented assessment to determine if the program was meeting the needs of the resident or the goal to decrease the number of incontinent episodes. The assessment forms further did not address the resident's falls sustained on [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] and [DATE] that found the resident incontinent with each of these falls and received a head injury that required hospitalization and subsequent death. Interview with CNA #5, on [DATE] at 11:25 AM, revealed Resident #20 was only toileted every two (2) hours, the same as the other residents. Interview with CNA #7, on [DATE] at 10:55 AM, revealed she toileted the resident every two (2) hours and as needed. Resident #20 wanted to do it by him/herself and did not want to ask for help. 2. Review of the clinical record for Resident #15 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #15 had a history of [REDACTED]. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident not steady on his/her feet and needed extensive assistance from staff to toilet, walk, transfer and bathe. The MDS further revealed staff could not conduct a Brief Interview for Mental Status (BIMS) due to the resident having short-term and long-term memory problems which affected his/her ability to make decisions and follow cues. The facility determined on the MDS the resident required supervision in daily decision making. The assessment further determined the resident was a candidate for a urinary toileting program. Review of the comprehensive care plan, dated [DATE], revealed the resident was on a Restorative Nursing Program scheduled toileting. Resident required restorative nursing scheduled toileting program related to decrease episodes of urinary incontinence and unsafe self transfers related to toileting needs. The undated interventions stated to observe skin for breakdown while toileting per individual schedule; encourage resident to use toilet in accordance with the program and as needed; evaluate restorative program quarterly and as needed; encourage resident to request staff assist to bathroom as needed at times other than scheduled toileting times. However, the comprehensive care plan did not provide direction to staff as to when to take the resident to the bathroom. Review of the Scheduled Toileting Program Plan revealed a flow sheet with a documentation key D-decline, V-toileted/voided, O-toileted-did not void, V/BM-toiled, voided and bowel movement. It further was divided into two sections one titled Continent Episodes only and Incontinent Episodes. The form contain a daily grid for each day and time noted as toilet prn during night; with AM care; after breakfast; after lunch; between 3P-5P, after supper; between 10P and 12A. The form further revealed it was not individualized, but toileting took place every two hours. Review of the Scheduled Toileting Program Plan, for Resident #15, dated [DATE], revealed nine (9) toileting times per day the resident was scheduled to be toileted. There were no entries made for one hundred and two (102) of the two hundred and seventy (270) toileting opportunities. Review of the Scheduled Toileting Program Plan, dated [DATE], revealed nine (9) toileting times per day the resident was scheduled. However, there was no entry made for fifty-five (55) of the two hundred seventy-nine (279) toileting opportunities. Review of the Scheduled Toileting Program Plan, dated [DATE], revealed nine (9) toileting times per day the resident was scheduled to be toileted. However, there were no entries made for sixty-eight (68) of the two hundred seventy-nine (279) toileting opportunities. Review of the Scheduled Toileting Program Plan, dated [DATE], revealed nine (9) toileting times per day the resident was scheduled to be toileted. However, there were no entries made for eighty-nine (89) of the one hundred sixty-two (162) toileting opportunities between [DATE] and [DATE]. No toileting documentation was completed on this sheet between [DATE] and [DATE]. Review of the Scheduled Toileting Program Plan, dated [DATE], revealed nine (9) toileting times per day the resident was scheduled to be toileted. However, there were no entries made for one hundred and fifty-seven (157) of the two hundred and seventy-nine (279) toileting opportunities. Review of the Scheduled Toileting Program Plan, dated [DATE], revealed nine (9) toileting times per day the resident was scheduled to be toileted. However, there were no entries made for one hundred and fifty-four (154) of the two hundred and seventy (270) toileting opportunities. Review of the Scheduled Toileting Program Plan, dated [DATE], revealed nine (9) toileting times per day. There were no entries made for one hundred and seventeen (117) of the two hundred and seventy-nine (279) toileting opportunities. Continued review of Resident #15's program revealed it did not address the three (3) falls the resident sustained [REDACTED]. On [DATE] the resident was taking self to the bathroom and fell receiving a laceration to left eyebrow. On [DATE] the resident was incontinent and fell with pain in the right shoulder. On [DATE] the resident was taking self to the bathroom and fell sustaining an abrasion to the back and a skin tear to the elbow. Interview with Certified Nursing Assistant (CNA) #9, on [DATE] at 12:00 PM, revealed she would toilet residents on the toileting program every two hours. She stated if a resident did not void she left the box blank on the toileting form. The CNA stated she had been trained on the toileting program, and her preceptor was another CNA and she was told to leave the area blank if the resident did not void or was not incontinent. Interview with CNA #3, on [DATE] at 10:55 AM, revealed the residents on the toileting program were toileted every two hours and as needed. Interview with CNA #6, on [DATE] at 1:55 PM, revealed the residents on the toileting program were toileted every two hours and before and after meals. Interview with the Restorative/Wound Care Licensed Practical Nurse (LPN), on [DATE] at 2:30 PM, revealed the scheduled toileting program was not the same as a Restorative toileting program; however, it was documented on the same forms. She further stated there were twenty-seven (27) residents who were on the scheduled toileting program and only two (2) of those residents had a different schedule from the rest. She stated residents were assessed for four (4) days to determine if they met the requirements to be on the scheduled toileting program. She stated the Certified Nursing Assistants documented the resident's continent and incontinent episodes on the Scheduled Toileting Program form. She stated all areas on the forms should be filled in using the key at the top of the page and there should be no blanks. She stated a quarterly and monthly assessment was completed on each resident to determine if the residents continued to qualify for the program. She stated she did not track or trend the information gathered regarding the residents toileting habits to determine if changes needed to be made to a resident's program to better meet their needs or to determine if the program was administered by nursing effectively. She stated the care plan for the toileting program was computerized and the computer automatically generated generic interventions for each resident's care plan. Interview with the Risk Manager, on [DATE] at 9:35 PM, revealed she had not completed any audits of the toileting program to determine if the program was effective or needed revisions. Interview with the Director of Nursing (DON) on, [DATE] at 3:00 PM, revealed the Restorative/Wound Care Licensed Practical Nurse, was responsible for assessing the toileting program to determine the program's effectiveness. But he was not aware there was documentation issues' occurring in regards to the toileting program until this week. He stated he thought it was important for her to tell him if there was a problem with the toileting program documentation sooner. The DON stated he did not know of any tracking and trending data completed by the Restorative/Wound Care LPN, in regards to the toileting program. Review of the Allegation of Compliance (AOC) revealed the facility implemented the following immediate steps to remove the Immediate Jeopardy: 1. The Medical Director was notified of Immediate Jeopardy and incidents causing the Immediate Jeopardy on Thursday [DATE]. 2. A representative of the Governing Body provided the Administrator guidance and education on physician and family notification, supervision and investigation of falls, care plan revisions and scheduled toileting programs on [DATE] and [DATE]. 3. Licensed nurses (DON, Staff Development Coordinator, Risk Care Manager, Restorative/Wound Care Nurse, Minimum Data Set Nurse, House Supervisor, two (2) Unit Managers and a Staff Nurse) completed an audit on [DATE] for the one hundred eleven (111) residents currently in the facility. This included thirty (30) residents who had a fall in the past three (3) months, and eighty-one (81) residents who had no fall within the past three (3) months. The audit included a review of the fall event document for those who had fallen for root cause of the fall, interventions added to the care plans at the time of the fall, times of scheduled toileting program (if any), alarms utilized, care plans, notifications made to the attending physician and resident's responsible party and interventions added after the audit was completed. An action taken as a result of the audit included update/revision to care plans for eleven (11) residents that included reachers; toileting in early morning hours; sensor pads; mattresses; and, non-skid strips to the floor. In addition, one resident's toileting program was addressed as a result of the [DATE] audit with changes to the timing of the toileting program based on his/her individualized needs. 4. The Medical Director met with the Director of Nursing (DON) on [DATE] to review policies, procedures and practices for physician notification, root cause analysis of accidents, incidents and falls prevention, revision of care plans and the scheduled toileting program. Revisions were made to the policy, Accident and Incidents, for physician and responsible party notification to include notification to the physician within thirty (30) minutes of a fall involving head injury or a fall which was not witnessed. Revision was made to the policy, Falls Prevention, to check safety devices each shift to ensure they are in place and functioning properly. 5. The procedure for conducting neurological checks was reviewed by the DON and the Staff Development Coordinator and all licensed nurses provided education on that process on [DATE] through [DATE]. The DON and the Staff Development Coordinator conducted the inservice training on neurological checks and additional pen lights (used to conduct the neurological checks) were ordered by the DON on [DATE]. 6. The MDS Coordinator, MDS Nurse, DON and Risk Manager are responsible for ensuring care plans are completed/revised in a timely/accurate manner. The care plans of residents who have fallen would be reviewed weekly in a Standards of Care meeting led by the MDS Nurse and the MDS Coordinator. In attendance at that meeting are the Dietary Manager, Risk Manager, Social Services Representative and the Activity Director. A report would be generated in that meeting of all falls, the review/revision of the residents' care plans and any actions taken to address concerns which would include staff education, staff discipline and care plan revisions to the Quality Assessment and Assurance Committee monthly from [DATE] - [DATE]. 7. The DON and the Staff Development Coordinator were provided training by the Administrator on [DATE] on physician and responsible party notification. The DON and the Staff Development Coordinator initiated all licensed nurses' and Certified Nursing Assistants' (CNA) training on [DATE] and continued that training through [DATE]. A total of one hundred nineteen (119) staff had been trained by 9:30 PM on [DATE] with one (1) remaining staff notified they must receive training by their supervisor prior to returning to work. The training to all licensed nurses and certified nursing assistants included: work order process, care plans, certified nursing assistant care sheets, proper use and types of alarms, the scheduled toileting program process/form to be used and proper completion of the form. The licensed nurses received training on: falls and proper process for notification of the resident's physician, the responsible party, the neurological check process, the proper completion of the Event Report Form, review/revision of care plans, root cause analysis process, policy and procedure on Accidents and Incidents, policy on Falls Prevention, Neurological check protocol form and the form used for the Scheduled Toileting Program. 8. The Administrator provided training to the Director of Nursing, the Risk Manager and therapy staff on [DATE] and [DATE] regarding the IJ, policy and procedure revisions, processes of Falls Committee Meeting, quality assessment and assurance committee role to ensure compliance and develop further actions to be taken. 9. Three (3) notifications of residents' who fell prior to [DATE] was made to the attending physicians and responsible party on [DATE] with one (1) physician and the responsible party notification of a fall which occurred on [DATE]. 10. A Falls Committee was initiated [DATE] to review fall interventions, to review reviewed/revised care plans and to complete root cause analysis for falls during the meeting. The Falls Committee is comprised of the Administrator, the DON, a MDS Nurse, Social Worker, Risk Care Manager, Restorative/Wound Care Nurse and the Rehabilitation Services Manager and meets Monday-Friday. 11. The DON provided training to the Restorative/Wound Care Nurse on [DATE], [DATE] and [DATE] addressing the facility's scheduled toileting program, the toileting program as it relates to falls, review of the four day bowel and bladder assessment process to note patterns and trends to develop an individualized scheduled toileting program for the resident, the process of documentation on the toileting program form and the creation of an audit tool to audit the clinical documentation relative to the toileting program, monitor for patterns and trends of the toileting program and a system to report findings of the audits to the Quality Assessment and Assurance Committee. 12. The Restorative/Wound Care Nurse would audit the toileting program using the Scheduled Toileting Audit tool. The toileting program documentation was to ensure accuracy and completeness of scheduled toileting programs. The audit would include completion of all fields on the toileting program document, issues noted, trends noted, updates to the toileting program and her initials. On [DATE] the Restorative/Wound Care Nurse audited twenty-nine (29) clinical records finding one (1) area of concern and on [DATE] she audited twenty-eight (28) clinical records finding one (1) area of concern. The Restorative/Wound Care Nurse is to report identified concerns with the toileting program to the DON and the Quality Assessment and Assurance Committee will review and monitor those findings. 13. The facility will utilize the Quality Assessment and Assurance Committee to review, evaluate and monitor for compliance with the notification of physician/responsible party, revision of resident care plans, toileting program and accidents and supervision with the following documents to be utilized: audits for falls, audits of notification of resident's attending physician/responsible party, audits of care plans addressing falls and audits of toileting program. The monthly meeting of the Quality Assessment and Assurance Committee to be held in February 2015 will be the initial meeting to review all of the audit information. These meetings will continue monthly for the next calendar year and will review the audit findings, assess the effectiveness of actions taken, revise action plans if necessary and continue to monitor the specifics of all falls within the facility. On [DATE], the State Survey Agency (SSA) validated the facility's AOC prior to exit through observation, interview and record review as follows: 1. Telephone interview with the Medical Director, on [DATE] at 2:30 PM, post survey due to lecture schedule and unavailability, revealed he was contacted by the Director of Nursing (DON) on [DATE] regarding the Immediate Jeopardy. The Medical Director revealed he and the DON discussed several issues in regard to the Immediate Jeopardy i.e. the cause of resident falls, toileting issues/toileting schedules, CNA education, review of residents' medications, use of non-skid socks/shoes (should always be available) and lighting. He also revealed he and the DON discussed revision of the residents' care plans as necessary and the revisions needed for facility policies; specifically Accidents/Incidents, Fall Prevention and the Toileting Program. The Medical Director indicated he told the DON the question should always be asked after a resident's fall where the facility failed and what should be done to prevent resident falls/accidents. 2. Review of the Administrator's notes from telephone conversation with a Governing Body representative revealed the representative retrained the Administrator on the need to ensure policies and procedures were in place (process of physician/family notification, supervision and falls, care plan revisions and scheduled toileting programs). Further review of the Administrator's notes from telephone conversation with a Governing Body representative on [DATE] revealed the representative addressed the process of root cause analysis which required intense and in-depth questioning, record review, and resident, staff and witness interviews. Also discussed during the [DATE] training of the Administrator by the Governing Body representative was tracking and trending of all falls and assurance audits are in place to ensure processes are being followed with concerns identified to be addressed in staff training. Interview with the Administrator, on [DATE] at 10:50 AM, revealed he had a telephone conversation with a Governing Body representative on [DATE] and [DATE] to include how to complete the process of physician/family notification when a resident had a fall, how to follow the facility policy regarding falls, care plan revisions, the scheduled toileting programs, and the process in-depth root cause analysis. 3. Review of the Resident Audit for Immediate Jeopardy [DATE] document revealed one hundred-eleven (111) residents (census of [DATE]) were reviewed for falls in the past three (3) months-date/time/root cause; interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit with signatures of nurses completing the audits. In addition, record review of Unsampled Resident C's individualized toileting program revealed it had been revised as a result of the audit on [DATE] with changes to reflect a time frame for toileting of 3:00 AM - 5:00 AM as the resident had fallen during those hours when attempting to self toilet. Interview with the DON on [DATE] at 10:00 AM revealed he was involved in the audit of all residents' charts who were in the facility on [DATE] to review all falls within the past three (3) months in regard-date/time/root cause, interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit. Interview with the Risk Manager, on [DATE] at 4:32 PM, revealed she was involved in the review of residents' falls for the past three (3) months that included the current census of one hundred and eleven (111) residents on [DATE] and the review covered the date/time/root cause, interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit. Interview with the Minimum Data Set nurse, on [DATE] at 3:44 PM, the Restorative/Wound Care Nurse, on [DATE] at 3:55 PM, two (2) Unit Managers on [DATE] at 4:45 PM, a Staff Nurse, on [DATE] at 5:05 PM, and the Staff Development Coordinator, on [DATE] at 5:30 PM, revealed they had all been involved in the audit of the facility residents on [DATE] to review all falls within the past three (3) months in regard-date/time/root cause, interventions added at time of fall, scheduled toileting and times, alarms type/location/ care plan updated at time of fall and any interventions added at time of audit. Record review of one resident's individualized toileting program revealed it had been revised as a result of the audit on [DATE] with changes to reflect a time frame for toileting of 3:00 AM - 5:00 AM as the resident has fallen during those hours when attempting to self toilet. 4. Review of the policy, Accident and Incidents, on [DATE] at 9:00 AM revealed it had been revised to include notification to the physician within thirty (30) minutes of a fall involving head injury or a fall which was not witnessed. Review of the policy, Falls Prevention, on [DATE] at 9:10 AM, revealed it had been revised to include the check of safety devices each shift to ensure they are in place and functioning properly. Interview with the Administrator and the DON, on [DATE] at 10:05 AM, revealed they had met with the Medical Director on [DATE] to review policies, procedures and practices for physician notification, root cause analysis of accidents, incidents and falls prevention, revision of care plans and the scheduled toileting program and they made revisions to the Falls Prevention and the Accident and Incidents policies. Observation, on [DATE] at 10:40 AM, revealed Resident #25 had an alarm on the wheelchair as care planned and on [DATE] at 1:00 PM, Resident #25 was seated in the wheelchair with an alarm on the wheelchair. Observation of Resident #27, on [DATE] at 8:15 AM and 1:25 PM, revealed an alarm on the resident's wheelchair. Review of the record for Resident #25 revealed the resident's alarm had been checked on day shift per facility policy and was functioning and review of Resident #27's record revealed the resident's alarm had been checked on the day shift per facility policy and was functioning. 5. Review, on [DATE] at 10:13 AM, of the content for an inservice to licensed nursing staff on [DATE] revealed the procedure for conducting neurological checks was reviewed by the Director of Nurses and Staff Development with the nurses and they were informed of additional pen lights (used during the neurological checks) being available in the facility on all of the crash carts. Review of two (2) medical supply company invoices on [DATE] revealed additional pen lights had been ordered by the Administrator for nurses to use during neurological checks. Observation of a neurological check performed by Licensed Practical Nurse (LPN) #4 on Resident #26, on [DATE] at 12:30 PM, revealed proper technique per standards of nursing practice and followed the facility's retraining for nurses on neurological checks. Interview with LPN #4, on [DATE] at 10:20 AM, revealed she had been retrained on neurological checks for residents with possible head injury during a training provided to all licensed nurses on [DATE] by the Staff Development Coordinator and she knew pen lights were available in the facility on the crash carts. 6. Interview with the Activity Director, on [DATE] at 3:50 PM, revealed she had been present on [DATE] in a Standards of Care meeting and had been involved in the review and revision of care plans for residents who had fallen. Interview with the MDS Coordinator, on [DATE] at 3:44 PM, revealed she was involved in the Standards of Care meetings weekly, on [DATE] and in the review or revision of care plans for residents who had fallen. 7. Interview and record review with the DON, on [DATE] at 2:19 PM, revealed he was provided training by the Administrator on [DATE] on physician/responsible party notification after a resident's fall. He revealed he and the Staff Development Coordinator began on [DATE] an all nursing staff training regarding the physician/responsible party notification after a resident's fall, and continued through [DATE]. A review of in-service training records on [DATE] revealed one hundred nineteen (119) staff had been trained by 9:30 PM on [DATE] as cross-referenced with the facility human resource department staff roster. The training also included: work order process; care plans; certified nursing assistant care sheets; proper use and types of alarms; the scheduled toileting program process/form to be used and proper completion of the form. The licensed nurses received training on: falls and proper process for notification of the resident's physician; the responsible party; the neurological check process; the proper completion of the Event Report Form; review/revision of care plans; root cause analysis process; policy and procedure on Accidents and Incidents; policy on Falls Prevention; Neurological check protocol form and the form u

Based on observation, interview and record review, it was determined the facility failed to ensure residents received care in a dignified manner for one (1) of thirty-two (32) sampled residents (Resident #3). Licensed Practical Nurse (LPN) #5 failed to respond to Resident #3's continuous calls for some one to assist him/her with repositioning for twenty-three (23) minutes while she passed medications next to and down the hall where Resident #3 lived. The findings include: The facility did not provide a policy regarding resident dignity. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/22/10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 03/21/14, and the Quarterly MDS Assessment, dated 11/14/14, revealed the facility assessed the resident as requiring extensive assistance with bed mobility, range of motion limitation in lower extremities, and use of [MEDICAL CONDITION] medication. The resident was assessed to be at risk for falls. Review of the Comprehensive Care Plan for Resident #3 revealed the facility developed a care plan on 03/02/10, with updated goals and target dates for 02/14/15. Problems on the care plan included the Potential for Falls and Potential for Injury related to [MEDICAL CONDITION] medication use, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) with a score of twelve (12) reflecting minimal cognitive impairment. Observations on 01/07/15 from 7:50 AM to 8:13 AM, revealed LPN #5 did not provide adequate supervision for Resident #3 as evidenced by Resident #3 pleas for help went unanswered. Observation of Licensed Practical Nurse (LPN) #5 on 01/07/15 at 7:50 AM, revealed she was at the medication cart near Resident #3's room. Resident #3 yelled from his/her room, "Help me please, someone help, I don't like laying on this side, help, hey help." LPN #5 pushed the medication cart down the hall and prepared medications to be administered. Resident #3 continued to yell, "Please will you do it, I don't want to, please help me, someone turn me over please." At 8:00 AM, LPN #5 was observed at the end of the hall and Resident #3 yelled louder, "Please, please, I want to turn over, come on, please!" "Come on now." "Please, not kidding when I say I want to turn over, please come on." LPN #5 continued with medication pass. Resident #3 continued to yell, "Where you at? Hey. I'm not going to wait to turn over, please." "Please somebody." At 8:05 AM, LPN #5 was observed beside Resident #3's room with the medication cart. Resident #3 yelled, "Please, Please. I want to turn over please." LPN #5 continued to prepare medication for administration. At 8:10 AM, LPN #5 was observed in the room next to Resident #3. Resident #3 yelled, "Please turn me over, please come on now. Come on. I don't care. Please turn me over. I hurt. Please turn me over. Turn me over." Observation at 8:13 AM, revealed LPN #5 was outside of Resident #3's room and standing at the medication cart when the Unit Manager (UM) walked up to her. The UM was observed answering Resident #3 from the hallway and walked into Resident #3's room. LPN #5 continued past Resident #3's room without entering. Interview with LPN #5, on 01/07/15 at 11:00 AM, revealed when she got near Resident #3's room to administer medication, she heard the resident call out. LPN #5 stated did not go into the resident's room because the UM went into the resident's room to assist. LPN #5 stated she was not familiar with Resident #3's care plan. Interview with Orchard UM, on 01/07/15 at 11:55 AM, revealed she went to speak to LPN #5 regarding another resident and she heard Resident #3 call out for assistance. The UM stated when she went into Resident #3's room; the resident was laying on his/her side facing the door and the resident asked to be turned. The UM stated all staff was responsible for seeing to the needs of the residents. Further interview with the UM revealed crying out in pain and begging to be turned was not the usual behavior for the resident. Interview with the Director of Nursing (DON), on 01/08/15 at 10:15 AM, revealed he expected staff to answer resident's call lights within five (5) minutes, emergency lights within three (3) minutes and a resident's call for help immediately. The DON further stated twenty-three (23) minutes was too long for a resident's cry for assistance to go unanswered. The DON stated call light audits were done monthly and if issues were noted, they were discussed with staff during in-services.

Based on observation, interview, record and policy review, it was determined the facility failed to have an effective system in place to ensure the comprehensive plan of care was implemented for two (2) of thirty-two (32) sampled residents (Resident #3 and Resident #16). The facility care planned Resident #3 to be turned and repositioned as needed due to pain, pressure and mobility. LPN #5 continued to pass medications and failed to respond to assist the resident to turn and reposition when he/she repeatedly cried out for someone to turn him/her because he/she was hurting. In addition, the facility failed to ensure Resident #16's bed alarm was functioning as care planned at the time of the resident's fall. The nurse discovered that the batteries to the alarm were missing. The findings include: Review of the facility's policy titled Comprehensive Care Plan, dated July 2009, revealed the comprehensive care plan would include measureable objectives and timetables to meet the resident's medical, nursing, and psychological needs as identified in the comprehensive assessment. The care plan would include items or services ordered, provided, or withheld. In addition, the care plan should address prevention of avoidable decline in functional status, and the resident's care needs. 1. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/22/10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 03/21/14, and the Quarterly MDS Assessment, dated 11/14/14, revealed the facility assessed the resident as requiring extensive assistance with bed mobility, and as having one (1) or more pressure ulcers at Stage I or higher. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) with a score of twelve (12) reflecting minimal cognitive impairment. Review of the Comprehensive Care Plan for Resident #3 revealed the facility developed a care plan on 03/02/10, with an updated goal and target date of 02/14/15, for the problem of Potential for Pain or Discomfort related to staged pressure ulcers, immobility, and [DIAGNOSES REDACTED]. Interventions listed included to observe for quality, intensity, duration, and frequency of pain symptoms and to position the resident for comfort as needed. Continuous observations, on 01/07/15 from 7:50 AM to 8:13 AM, revealed Resident #3's pleas for help with repositioning went unanswered. Observation, on 01/07/15 at 7:50 AM, revealed Licensed Practical Nurse (LPN) #5 was at the medication cart near Resident #3's room. Resident #3 yelled from his/her room, "help me please, someone help, I don't like laying on this side, help, hey help." LPN #5 pushed the medication cart down the hall and prepared medications to be administered. Resident #3 continued to yell, "Please will you do it, I don't want to, please help me, someone turn me over please." Observation, on 01/07/15 at 8:00 AM, revealed LPN #5 was at the end of the hall and Resident #3 yelled louder, "Please, please, I want to turn over, come on, please! Come on now. Please, not kidding when I say I want to turn over, please come on." LPN #5 continued with the medication pass. Resident #3 continued to yell, "Where you at? Hey, I'm not going to wait to turn over, please, please somebody." The resident could not turn them self or reposition. Observation, on 01/07/15 at 8:05 AM, revealed LPN #5 was beside Resident #3's room with the medication cart. Resident #3 yelled, "Please, please, I want to turn over please." LPN #5 continued to prepare medication for administration. At 8:10 AM, LPN #5 was observed in the room next to Resident #3. Resident #3 yelled, "Please turn me over, please come on now. Come on, I don't care. Please turn me over, I hurt. Please turn me over. Turn me over." Observation at 8:13 AM, revealed LPN #5 was outside of Resident #3's room and standing at the medication cart when the Unit Manager (UM) walked up to her. The UM was observed answering Resident #3 from the hallway and walked into the resident's room. LPN #5 continued past Resident #3's room without entering. Interview with Resident #3, on 01/07/14 at 8:15 AM, revealed the resident felt much better since he/she had been repositioned and was now on his/her back. Interview, on 01/07/15 at 11:00 AM, with LPN #5 revealed when she got near Resident #3's room to administer medication, she heard the resident call out, but she did not go into the room because the UM went into Resident #3's room to assist. Further interview with LPN #5 revealed she was not familiar with Resident #3's care plan. LPN #5 stated residents should be turned at least every two (2) hours by the Certified Nurse Aides (CNAs). LPN #5 stated she monitored the CNAs' turning of residents by comparing the residents' positions to how they were positioned the last time she observed them. Interview, on 01/07/15 at 11:55 AM, with the Orchard Unit Manager (UM), revealed she went to speak to LPN #5 regarding another resident and she heard Resident #3 call out for assistance. The UM stated when she went into Resident #3's room; the resident was laying on his/her side facing the door and the resident asked to be turned. She assisted by repositioning Resident #3 onto his/her back. The UM stated crying in pain and begging to be turned was not the usual behavior for the resident. The UM stated all staff was responsible for seeing to the needs of the residents. The UM further stated she attended all residents' care plan meetings with their families, but she did not know Resident #3's care plan off the top of her head. Interview, on 01/08/15 at 10:15 AM, with the Director of Nursing (DON), revealed he expected staff to answer resident's call lights within five (5) minutes, emergency lights within three (3) minutes and a resident's call for help, immediately. The DON further stated twenty-three (23) minutes was too long for a resident's cry for assistance to go unanswered. The DON stated call light audits were completed monthly and if issues were noted, they were discussed with staff during in-services. 2. Review of Resident #16's clinical record revealed the facility originally admitted the resident on 08/05/10, and readmitted the resident on 01/20/11 with [DIAGNOSES REDACTED]. Continued review of Resident #16's clinical record revealed he/she received routine anticoagulation therapy ([MEDICATION NAME]) along with [MEDICATION NAME] and Aspirin for a [DIAGNOSES REDACTED].#16's Minimum Data Set (MDS) assessment, dated 12/10/14, revealed falls was a triggered care area. Review of the Comprehensive Care Plan, dated 02/20/14, revealed a care plan for falls with multiple interventions, which included a sensor pad/alarm to the resident's bed; however, it did not give direction as to who, how, or when the alarm was to be checked for function or to check the batteries. Review of the Nurses' Notes revealed it was documented that Resident #16 was found, on 12/30/14 at 2:45 AM, with his/her body half on the bed, and half on the floor. The Nurse's Note stated the resident had no apparent injuries, but neurological (neuro) checks were initiated by the facility's protocol. The Physician was notified later that morning at 10:40 AM and returned the call at 12:05 PM. Review of the facility's Investigation, revealed it was documented that three (3) hours prior to the incident, Resident #16 was awake, talking and reclining on his/her bed. But, at 2:45 AM Certified Nursing Assistant (CNA) #5 observed Resident #16 sitting on the floor on the fall mat beside his/her bed. When the unit's licensed nurse inspected the sensor pad on the bed, the batteries that powered the device were missing. Interview, on 01/09/15 at 9:35 AM, with CNA #5 revealed she was assigned to provide care to Resident #16 on the second shift on 12/29/14 and on the third shift on 12/30/14. CNA #5 stated she prepared the resident for bed by performing perineal care, putting the bed in lowest position, and placing the floor mat beside the bed. However, CNA #5 stated she forgot to check the sensor alarm for function before leaving Resident #16's room. CNA #5 stated that during the early morning hours of 12/30/14 at 2:45 AM, she entered Resident #16's room, turned on the light and saw the resident seated by the bed and on the floor mat. CNA #5 stated Resident #16 was confused. Continued interview with CNA #5 revealed the facility's Staff Development Nurse provided a written in-service on tab and bed alarms. The facility's insevice instructed staff that it was the CNA's responsibility to be sure the alarms had batteries and were functioning. CNA #5 stated that she could not remember exactly when that in-service occurred. CNA #5 stated Resident #16 was supposed to have a long sensor pad on his/her bed, and the alarm on the pad should sound if the resident tried to get up from bed. CNA #5 stated the staff person responsible for caring for the resident was supposed to test the residents' alarms during his/her rounds at the beginning of the shift. CNA #5 stated she failed to check Resident #16's alarm for functioning. Interview, on 01/08/15 with the Unit Manager (UM) for the Orchard Unit, revealed she learned about Resident #16's fall on 12/30/14 during the morning staff meeting. The UM stated the night nurse told her the sensor alarm was not working, and the entire box (unit) for the alarm was changed out after CNA #5 found the resident on the floor. The UM stated it was the CNA's responsibility to check the bed/chair alarms each shift to ensure they had batteries and were functioning. The UM stated she did not know if the night nurse had re-educated CNA #5 to check the residents' bed or chair alarms for batteries and function at the beginning of each shift. Interview, on 01/09/15 at 3:40 PM, with the Director of Nursing (DON) revealed CNAs were responsible for checking residents' bed and chair alarms. In addition, the CNAs were to sign off in a log book, at the end of their shifts, to verify the residents' bed and chair alarms had been checked and were functioning. The DON further stated that he, the shift supervisor, and each unit's licensed nurses, were responsible for ensuring all residents' bed and chair alarms were working, and that all safety measures were in place to protect the residents from potential injury, as care planned.

Based on interview, review of the facility's investigation and policies it was determined the facility's Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, or psychosocial well-being of each resident. The facility failed to ensure policy and procedures were implemented to provide adequate supervision of residents identified to be at high risk for elopement for one (1) of twenty (20) sampled residents. Resident #1 exited the facility without staff knowledge or supervision on 01/31/12, and self-propelled a wheelchair along the residential street in front of the facility (Boxwood Run Road). The wheelchair slipped off of the pavement as an off-duty staff approached Resident #1 on Boxwood Run Road, and the wheelchair rolled over and the resident fell out of the wheelchair and onto the grass at the roadside. The resident was returned to the facility uninjured. The facility failed to ensure staff received training regarding elopement after the incident and failed to report the incident to the appropriate State Agencies. (Refer to F225, F282, F323) The facility's failure to be administered effectively placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/22/12 and was found to exist on 01/31/12. The facility provided a credible Allegation of Compliance (AOC) on 03/30/12. The State Agency verified Immediate Jeopardy was removed on 03/25/12 prior to exit on 03/30/12; which lowered the scope and severity to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of implemented action plans and training to achieve and maintain compliance. The findings include: Review of the facility's Abuse Prohibition Policy, issued 07/2010, revealed it is the policy of this facility that parameters will be established regarding abuse in the areas of screening, training, prevention, identification, investigation, protection and reporting/response. All facility employees are to promptly report any suspected abuse, mistreatment, involuntary seclusion, neglect or misappropriations of property belonging to residents to the charge nurse immediately. The policy included a section listed as Reporting, which stated all incidents are reported and investigated as they occur. Review of the facility policy for Elopement, dated May 2010, detailed all residents were assessed on admission for elopement risk, then quarterly, and as needed thereafter. Residents found to be at risk for elopement were assigned a Code Alert bracelet. Residents who wandered outside or eloped from the facility property were reported to the State Agency 'as required' by the Director of Nursing (DON) or the Administrator. The policy did not include a definition of elopement. Review of the facility policy for Fifteen (15) Minute tracking, dated December 2011, revealed residents who required increased supervision were monitored by staff on fifteen (15) minute intervals to observe and document the resident's position in the facility. Review of the facility Investigation Report, which included the Morning Meeting Notes dated 08/15/11, revealed the SDC was assigned to, "look at the event report on resident getting out." Review of the Morning Meeting Notes dated 08/16/11, revealed a safety discussion regarding the Physical Therapy Main Entrance hours of access due to Resident #1, exit of the facility on 08/13/11. Review of the Event Report, dated 01/31/12, detailed that Resident #1 was "outside, the w/c was noted to fall over in a grassy area, resident alarm attached, resident on right side". The Event Report documented the incident as a "witnessed fall", with an immediate need for a care plan update to address a witnessed fall with facility interventions identified to be: neuro checks, change of the resident's Code Alert bracelet, and placement of a new Code Alert bracelet to the left ankle. Interview, on 03/15/12 at 4:00 PM, by telephone, and further interview on 03/20/12 at 8:20 AM, with the Dietary Aide (DA) revealed he left work at the end of his scheduled shift on 01/31/12 between 3:30 PM and 4:00 PM noticed Resident #1 in a wheelchair near the Physical Therapy entrance. Resident #1 continued to self-propel in the wheelchair toward the street in front of the facility (Boxwood Run Road). The DA said Resident #1 was always in sight from the rear view mirror in the car, and said two (2) cars passed the resident in the wheelchair on Boxwood Run Road. The DA continued to drive to the end of Boxwood Run Road and parked. The DA said Resident #1 was moving fast toward Highway 44 which intersected with Boxwood Run Road. The DA moved toward Resident #1 to return the resident to the facility; however, upon approach, a wheel of the chair went off of the pavement and rolled over, and Resident #1 fell out of the wheelchair into a grassy area. The DA returned Resident #1 to the wheelchair and returned the resident to the facility. The DA entered the Physical Therapy front entrance and did not hear an alarm when the resident was returned through the door. Interview, on 03/21/12 at 11:00 AM, with the Director of Nursing (DON) revealed the facility investigation did not identify any staff who heard the Code Alert alarm on 01/31/12 when Resident #1 exited the facility. The DON said the facility determined Resident #1 likely exited from the Physical Therapy Entrance. The DON said the facility determined that fifteen (15) minute Tracking had been an effective intervention to provide adequate supervision for Resident #1. The DON defined elopement as unwitnessed or unsupervised exit of the property, and said Resident #1 did not elope on 01/31/12 because the DA had eyes on Resident #1 during the duration of the event, though the facility investigation did not identify any staff who saw Resident #1 exit the facility. The DON said Resident #1 was not at a risk of serious injury, harm, impairment, or death while self-ambulating in a wheelchair on Boxwood Run Road. However, the DON said it was a potential that Resident #1 could have been hit by a car on Boxwood Run Road. Interview, on 3/16/12 at 12:20 PM, with the Administrator revealed the facility had not experienced any resident elopements since May, 2011. The Administrator provided a signed and dated statement: "We have not had any elopements since May 2011. We have had residents exit seeking, and exit facility but not any we consider elopements." Interview, on 03/21/12 at 6:01 PM, with the Administrator revealed the facility was capable of meeting the needs of Resident #1 at the facility, and said the only intervention the facility had not attempted was a one-to-one observation by staff. Interview, on 03/30/12 at 10:50 AM, with the Administrator revealed his most recent training regarding elopement was provided by the Governing Body/President/Owner of the facility on 03/22/12 and 03/23/12 via telephone conference call and was done as a result of survey findings. Interview on 03/28/12 with the Administrator revealed facility management staff were not trained on supervision of residents until prior to the review and audit of care plans and CNA care sheets conducted 03/22- 23/12. Review of the Allegation of compliance (AOC) revealed the facility took the following immediate actions: 1. Elopement assessments which included the complete resident census of one-hundred three (103) beginning the assessments on 03/22/12 and completed on 03/23/12. The facility determined thirteen (13) residents to be at risk for elopement. 2. The facility audited and revised the Certified Nursing Assistant (CNA) sheets on 03/23/12 for the thirteen (13) residents that were found to be a risk for elopement. 3. The facility educated the staff on 03/24/12 to include policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads including elopement definition and reporting. 4. The facility initiated Resident Tracking Sheets for the residents determined to require every fifteen minute checks. Staff are to document at fifteen (15) minute intervals at the time the resident is observed. 5. The facility closed the double doors between the Therapy Addition and Transition Way Unit and staff were directed to leave the doors closed. This door requires a coded entry. 6. The Director of Nurses and Maintenance Director checked all doors and alarms to ensure they were functioning properly. 7. The Unit Manager provided education to the staff on duty regarding every 15 minute checks. 8. Department Heads and Administrative staff were provided education and the facts of the incident by the Administrator on 03/22/12. 9. The elopement binder is to be reviewed weekly on Fridays by the Administrator to ensure the photographs and face sheets are in the binder. 10. The Resident Safety Policy was reviewed and revised with a new definition of elopement, response to alarms, checking the area around the alarm, determining the cause of the alarm to sound and documentation on the code alert log. In addition, a form was created, Acknowledgement of Risks/Criteria: Being Outside Facility Unsupervised that will be presented to residents and/or their responsible parties. Policies reviewed: Missing Resident; Wandering and Elopement of Residents; Resident Tracking and Exits with Key Pads. A missing resident quiz was created for staff to complete during inservice training. 11. The Administrator received training by the Governing Body on 03/22/12 and 03/23/12 in response to the survey findings including elopement and reporting. The State Agency validated the AOC as follows: 1. The State agency validated documentation of elopement assessments which included the complete resident census of one-hundred three (103). The resident Elopement assessment scores were documented, and it was determined that thirteen (13) of one-hundred three (103) residents were at risk for elopement. The facility began the assessments on 03/22/12, and were completed on 03/23/12. It was verified on 03/30/12, that the facility reviewed and updated care plans for all thirteen (13) residents determined by the facility to be at risk for elopement 2. The State agency validated documentation of audits of audits comparing CNS sheets to assessments and careplans and revisions to the Certified Nursing Assistant (CNA) sheets that was completed on 03/23/12 for the thirteen (13) residents that were found to be a risk for elopement. It was verified by review of all thirteen (13) CNA sheets for residents at risk for elopement, that the revisions were completed on 03/23/12. 3. The State agency validated documentation of education provided to staff which included policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads. The facility staff roster indicated there were one-hundred and fifty-five (155) staff and one-hundred and forty-two (142) had been educated by 03/24/12 on the policies and procedures. The facility provided documentation of a detailed plan to train the remainder of the staff prior to their date of return to work. 4. The State agency validated on 03/30/12, by observation of four (4) residents who were found to be at risk for elopement, that each resident had a Resident Tracking Sheet which accompanied each resident as they moved through the facility to Activities, Dining, etc. It was determined by observation, staff were documenting on the Resident Tracking Sheets in fifteen (15) minute intervals at the time of the resident observation. Interview with a staff member on 03/30/12 at 6:20 PM, revealed when a resident with fifteen (15) minute tracking moved to another area of the facility, documentation on the Resident Tracking sheet was completed by the staff member who accompanied the resident to that area. 5. Interviews on 03/30/12 at 6:30 PM with five (5) CNA's, three (3) RN's, two (2) LPN's, one (1) dietary staff, and one (1) medical records staff revealed that all staff members were able to state the steps staff were responsible for when a resident was missing, responsibilities of staff when a resident is on Resident Tracking, and a resident who wandered near a facility exit door. In addition, staff were able to identify elopement and were knowledgeable of reporting such. 6. Interview with the Administrator, on 03/30/12 at 10:50 AM, revealed he had received training in supervision, wandering residents, elopement-definition, and policies specific to the facility's needs. 7. The State Agency validated education of the Department Heads through interview with Staff Development, Activities, Medical Records, and Social Services, on 03/30/12 between 5:20 PM and 6:00 PM.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement the facility interventions on the Comprehensive Care Plan for one (1) of twenty (20) sampled residents (Resident #1) regarding elopement risk. The Comprehensive Care Plan detailed interventions to address elopement and wandering for Resident #1 to include: Fifteen (15) minute tracking including observation and documentation of resident behavior as it occurred, use of the Code Alert bracelet with check of function and placement every eight (8) hours, elopement assessment per policy schedule, and alert staff to resident's wandering behavior. Resident #1 had a history of [REDACTED]. Resident #1 exited the facility on 01/31/12 without staff supervision or knowledge and self-propelled in a wheelchair through the parking lot onto a residential street in front of the facility (Boxwood Run Road). The residents wheelchair tipped over and the resident fell into a grassy area on the side of the road. Resident #1 was returned to the facility by an off-duty staff member. The facility's failure to follow the plan of care placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/22/12 and was found to exist on 01/31/12. The facility provided a credible Allegation of Compliance (AOC) on 03/30/12 and the State Agency verified Immediate Jeopardy was removed on 03/25/12 prior to exit on 03/30/12, at 42 CFR 483.13 Resident Behavior and Facility Practices; 42 CFR 483.20 Resident Assessment, F282; 42 CFR 483.25 Quality of Care, F323; and 42 CFR 483.75 Administration, F490 which lowered the scope and severity to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of implemented action plans to achieve and maintain compliance. The findings include: The facility did not have a policy on following the Comprehensive Care Plan. Record review of the facility's policy for Resident Tracking, dated December 2011, revealed residents who were in need of increased supervision would be placed on 15 minute tracking. The policy detailed that the nurse would initiate a tracking sheet for residents who needed increased supervision, and the residents "position" would be documented in fifteen (15) minute intervals. The Resident Tracking policy also stated the nurse assigned to the resident was responsible to complete the documentation on the tracking form. Record Review of the facility's policy for Wandering and Elopement of Residents, dated 05/10, revealed all residents would be assessed upon admission by use of the Elopement Risk Assessment form. Each resident was to be assessed quarterly, and as needed thereafter. Record review of the Resident Tracking Sheet regarding Wandering, dated 03/24/12 through 03/25/1, revealed the documentation did not include the exact time or location of the resident each time an observation of Resident #1 was made. Review of the clinical record for Resident #1 revealed the facility admitted the resident, with [DIAGNOSES REDACTED]. The facility's elopement risk assessments revealed the facility reassessed Resident #1 for continued risk of elopement on 07/10/11, 10/12/11, 01/01/12, and 02/20/12 and the facility found the resident to be at high risk for elopement related to cognitive deficit and exit seeking behavior. Review of the care plan, dated 07/19/11, for Resident #1, revealed facility interventions to perform the elopement assessment quarterly and as needed, and to check the Code Alert bracelet function and placement every eight hours or every shift. A care plan to address wandering and exit seeking behaviors was implemented by the facility for Resident #1 and detailed the staff was responsible to observe and document resident behaviors and be alert to the resident wandering. Resident #1 had fifteen (15) minute tracking reordered on [DATE] after Resident #1 exited the building on that date and continued. Interview, on 03/20/12 at 4:03 PM, with Certified Nurse Assistant #4 (CNA #4), revealed the nurse was responsible to ensure the fifteen (15) minute tracking was documented. CNA #4 said the facility did not provide any education/training regarding resident elopement as a result of the exit from the facility on 01/31/12 by Resident #1. Interview, on 03/20/12 at 3:50 PM, with CNA #3 revealed she was aware Resident #1 was on fifteen (15) minute tracking and stated the nurse was responsible to complete the tracking sheet, and the CNA assignment sheet included notification to the CNA of the need for constant monitoring of Resident #1. CNA #3 said the facility did not provide education/training regarding resident elopement as a result of the exit from the facility on 01/31/12 by Resident #1. Interview, on 03/30/12 at 4:00 PM, with the Unit Manager (UM) revealed staff were expected to document on the Resident Tracking Sheet every fifteen (15) minutes, and said it was not acceptable to document in groups of observations by a line through the grid on the form to the end of a nursing shift, because it would not reflect the exact time of the resident observation. Interview, on 03/28/12 at 10:25 AM, with the DON revealed the Resident Tracking Sheets were supposed to be completed by each nurse, every fifteen (15) minutes to validate the resident's current location, if the resident required redirection, if the resident posed a problem, and the nurse's initials. Review of the Allegation of Compliance (AOC) revealed the facility took the following immediate actions: 1. Elopement assessments which included the complete resident census of one-hundred three (103) beginning the assessments on 03/22/12 and completed on 03/23/12. The facility determined thirteen (13) residents to be at risk for elopement. 2. The facility audited and revised the Certified Nursing Assistant (CNA) sheets on 03/23/12 for the thirteen (13) residents that were found to be a risk for elopement. 3. The facility educated the staff on 03/24/12 to include policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads including elopement definition and reporting of incidents. 4. The facility initiated Resident Tracking Sheets for the residents determined to require every fifteen minute checks. Staff are to document at fifteen (15) minute intervals at the time the resident is observed. 5. The facility closed the double doors between the Therapy Addition and Transition Way Unit and staff were directed to leave the doors closed. This door requires a coded entry. 6. The Director of Nurses and Maintenance Director checked all doors and alarms to ensure they were functioning properly. 7. The Unit Manager provided education to the staff on duty regarding every 15 minute checks. 8. Department Heads and Administrative staff were provided education and the facts of the incident by the Administrator on 03/22/12. 9. The elopement binder is to be reviewed weekly on Fridays by the Administrator to ensure the photographs and face sheets are in the binder. 10. The Resident Safety Policy was reviewed and revised with a new definition of elopement, response to alarms, checking the area around the alarm, determining the cause of the alarm to sound and documentation on the code alert log and reporting incidents. In addition, a form was created, Acknowledgement of Risks/Criteria: Being Outside Facility Unsupervised that will be presented to residents and/or their responsible parties. Policies reviewed: Missing Resident; Wandering and Elopement of Residents; Resident Tracking and Exits with Key Pads. A missing resident quiz was created for staff to complete during inservice training. 11. The Administrator received training by the Governing Body on 03/22/12 and 03/23/12 in response to the survey findings including elopement and reporting of incidents. The State Agency validated the AOC as follows: 1. The State agency validated documentation of elopement assessments which included the complete resident census of one-hundred three (103). The resident Elopement assessment scores were documented, and it was determined that thirteen (13) of one-hundred three (103) residents were at risk for elopement. The facility began the assessments on 03/22/12, and were completed on 03/23/12. It was verified on 03/30/12, that the facility reviewed and updated care plans for all thirteen (13) residents determined by the facility to be at risk for elopement 2. The State agency validated documentation of audits comparing CNS sheets to assessments and careplans and revisions to the Certified Nursing Assistant (CNA) sheets that was completed on 03/23/12 for the thirteen (13) residents that were found to be a risk for elopement. It was verified by review of all thirteen (13) CNA sheets for residents at risk for elopement, the revisions were completed on 03/23/12. 3. The State agency validated documentation of education provided to staff which included policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads. The facility staff roster indicated there were one-hundred and fifty-five (155) staff and one-hundred and forty-two (142) had been educated by 03/24/12 on the policies and procedures. The facility provided documentation of a detailed plan to train the remainder of the staff prior to their date of return to work. 4. The State agency validated on 03/30/12, by observation of four (4) residents who were found to be at risk for elopement, that each resident had a Resident Tracking Sheet which accompanied each resident as they moved through the facility to Activities, Dining, etc. It was determined by observation, staff were documenting on the Resident Tracking Sheets in fifteen (15) minute intervals at the time of the resident observation. Interview with a staff member on 03/30/12 at 6:20 PM, revealed when a resident with fifteen (15) minute tracking moved to another area of the facility, documentation on the Resident Tracking sheet was completed by the staff member who accompanied the resident to that area. 5. Interviews on 03/30/12 at 6:30 PM with five (5) CNA's, three (3) RN's, two (2) LPN's, one (1) dietary staff, and one (1) medical records staff revealed that all staff members were able to state the steps staff were responsible for when a resident was missing, responsibilities of staff when a resident is on Resident Tracking, and a resident who wandered near a facility exit door. In addition, staff were able to identify elopement and were knowledgable of reporting incidents. 6. Interview with the Administrator, on 03/30/12 at 10:50 AM, revealed he had received training in supervision, wandering residents, elopement-definition, and policies specific to the facility's needs. 7. The State Agency validated education of the Department Heads through interview with Staff Development, Activities, Medical Records, and Social Services, on 03/30/12 between 5:20 PM and 6:00 PM.

Based on observation, interview, record review, and review of the facility's investigation report and Abuse Prohibition Policy, it was determined the facility failed to report an elopement and an injury of an unknown source for two (2) of twenty (20) sampled residents. (Resident #1 and #14). On 01/31/12, Resident #1 exited through a Code Alert door without staff knowledge, then self-propelled in a wheelchair through the parking lot and onto the street in front of the facility (Boxwood Run Road). Resident #1 fell out of his/her wheelchair as an off duty staff member approached the resident on the street. The resident was returned the resident to the facility and assessed to have no injuries. The facility failed to report Resident #1's elopement to the appropriate State Agencies. In addition, Resident #14 sustained a fracture of unknown source identified on 03/19/12, which was not reported to the State Agencies. The facility's failure to report the elopement placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/22/12 and was found to exist on 01/31/12. The facility provided a credible Allegation of Compliance (AOC) on 03/30/12. The State Agency verified Immediate Jeopardy was removed on 03/25/12 as alleged prior to exit on 03/30/12; which lowered the scope and severity to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of implemented action plans to achieve and maintain compliance. The findings include: Review of the facility's Abuse Prohibition Policy, issued 07/2010, revealed it is the policy of this facility that parameters will be established regarding abuse in the areas of screening, training, prevention, identification, investigation, protection and reporting/response. All facility employees are to promptly report any suspected abuse, mistreatment, involuntary seclusion, neglect or misappropriations of property belonging to residents to the charge nurse immediately. The policy included a section listed as Reporting, which stated all incidents are reported and investigated as they occur. Review of the facility's policy regarding Wandering and Elopement of Residents, dated May 2010, detailed the Director of Nursing (DON) or Administrator would notify the State Agency of an incident of elopement as required. However, the policy failed to define elopement. 1. Review of the facility Event Report, dated 01/31/12 revealed Resident #1 was outside and the wheelchair fell over in a grassy area. The problem was identified on the Event Report as a "witnessed fall", and the immediate facility intervention was to change the Code Alert bracelet and apply a new bracelet to the left ankle, add a bracelet to the wheelchair, and Resident #1 remained on fifteen (15) minute tracking. The Post Event Investigation described the type of event as "witnessed fall, resident outside, wheelchair noted to fall over, and the facility intervention was: fifteen (15) minute tracking, Code Alert band on resident and wheelchair, continue tab alarm to bed and wheelchair, sensor pad to bed and wheelchair". Review of the clinical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. On 07/09/11, the facility assessed the resident at high risk for elopement related to cognitive deficit and exit seeking behavior. Resident #1 was care planned for wandering and exit seeking behavior and staff was to observe and document resident behaviors, and alert staff to wandering behaviors. The resident had a Code Alert bracelet to alert staff of an attempt to elope and the bracelet was to be checked for placement and function every shift. On 08/13/11, Resident #1 exited the facility, the Code Alert Alarm sounded, and the resident was returned to the facility from the parking lot. At that time Resident #1 was placed on and remained on fifteen (15) minute tracking. However, Resident #1 exited the facility on 01/31/12 without staff knowledge. Interview, on 03/15/12 at 4:00 PM, by telephone, and further interview on 03/20/12 at 8:20 AM, with the Dietary Aide (DA) revealed he left work at the end of his scheduled shift on 01/31/12 between 3:30 and 4:00 PM. The DA stated that he exited the building and went to his car at the lot behind the facility. As the DA was leaving the parking lot, he noticed a staff member who was pushing a male resident in a wheelchair. When the DA drove around the building to the front, he noticed Resident #1 in a wheelchair near the overhang of the Physical Therapy entrance. The DA thought Resident #1 was with the staff member and male resident seen behind the building, until the DA noticed Resident #1 continued to self-propel in the wheelchair toward the street in front of the facility (Boxwood Run Road), and the DA could not see the staff member with the male resident. Per interview, Resident #1 self propelled down the street; the wheel of the wheelchair slipped off the pavement; the wheelchair turned over; and, Resident #1 fell out of the wheelchair onto a grassy area. The DA returned Resident #1 to the wheelchair and returned the resident to the facility. The DA entered the Physical Therapy front entrance and did not hear an alarm when the resident was returned through the door. Interview on 03/16/12 at 11:15 AM, with the Maintenance Director and the Assistant Maintenance Director said when Resident #1 exited the facility, it was not considered an elopement because a staff member (DA) was watching the resident and knew of the resident's location. Interview, on 03/16/12 at 2:50 PM, with RN #1 revealed elopement was defined as a resident who was off of the facility grounds without someone supervising the resident. Per intervew, RN #1 did not remember any education or training of staff regarding elopement since Resident #1 exited the facility on 01/31/12. Interview, on 03/16/12 at 1:00 PM, with the Unit Manager (UM) of Orchard Way, revealed that the facility had not experienced any "true elopements" and said that some residents did get through the door into the parking lot, but no residents had left the facility property. The UM defined elopement as a resident who left the facility property. Interview, on 03/21/12 at 11:00 AM, with the Director of Nursing (DON) revealed that he was notified by the Staff Development Coordinator that Resident #1 had exited the facility on 01/31/12 without supervision. The DON did not consider the exit from the facility by Resident #1 to be an elopement and did not determine a cause, because the Dietary Aide had eyes on the resident the whole time. The DON said Resident #1 "was supervised, I know that." Further interview with the DA on 03/20/12 at 8:20 AM revealed he was interviewed by the Director of Nursing (DON) and the Administrator and was told by the Administrator that the State Agency would be involved with the elopement of Resident #1. Interview, on 03/21/12 at 3:35 PM, with the Administrator revealed he was responsible for reporting to the State Agencies. When Resident #1 exited the facility on 01/31/12 without staff supervision, the event was not considered an elopement, and therefore was not reported to the State Agency because the Administrator determined the resident was under supervision while outside of the facility. The Administrator said he did not wish to label the event as an elopement and said he would only state that Resident #1 was not witnessed crossing the threshold to exit the facility by anyone. The Administrator provided a hand written statement, dated 03/16/12 at 12:20 PM that stated, they had not had any elopements since May, 2011. They had residents exit seeking and exit the facility, but not any they consider elopements. The Administrator was the person responsible for invetigating any incidents. The Administrator and Director of Nursing discussed the event together and make a joint decision it was not an elopement or reportable. 2. Review of the clinical record for Resident #14, revealed the facility admitted the resident on 03/01/11, with [DIAGNOSES REDACTED]. The facility completed a quarterly Minimum Data Set (MDS) assessment on the resident on 01/23/12 and determined the resident was alert and oriented. The facility assessed the resident as requiring extensive assistance for all care needs. The physician ordered hospice care on 05/22/11. An X-Ray on 03/19/12 revealed a displaced humeral neck oblique fracture and osteopenia was present. Review of the facility's investigation of bruising of unknown origin for Resident #14, revealed staff was aware the resident had bruising and swelling from the resident's axilla to the fingertips on 03/17/12. The Director of Nursing (DON) was notified of the bruising to Resident #14 on 03/19/12. It was determined the investigation was thorough; however, it did not determined a cause. Interview with Certified Nurse Assistant (CNA) #2, on 03/27/12 at 2:00 PM, revealed she saw Resident #14's bruised arm on 03/17/12 and did not report this to anyone. She stated, she assumed it had already been reported. Interview with CNA #1, on 03/27/12 at 2:45 PM, revealed he saw Resident #14's bruised arm on 03/17/12 and thought for sure it must have been reported. He stated he should have reported it to the charge nurse. Interview, with the DON, on 03/27/12 at 1:30 PM, revealed he took a quick look at the bruising, on 03/19/12 around 9:30 AM, and was not concerned it was possible abuse nor had he determined the cause of the bruising. He stated he was not sure if he looked at the resident's whole arm to determine the extent of the injury. Continued review of the facility's investigation of Resident #14's bruising of the arm, revealed several staff members were aware of the resident's injury prior to 03/19/12. Interview with the DON, on 03/27/12 at 1:30 PM, revealed he talked with hospice on 03/22/12 and discovered hospice was going to report the bruising of unknown origin identified on the arm of Resident #14. He stated, he told hospice he wanted to be the one to report to the state agencies. He stated, he decided to report the injury after he spoke with hospice. Per interview, the DON had not received training on how to recognize potential abuse or investigate. Review of the Allegation of compliance (AOC) revealed the facility took the following immediate actions: 1. The facility educated the staff on 03/24/12 to include policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads including elopement difinition and reporting of incidents. 2. Department Heads and Administrative staff were provided education and the facts of the incident by the Administrator on 03/22/12. 3. The Resident Safety Policy was reviewed and revised with a new definition of elopement, response to alarms, checking the area around the alarm, determining the cause of the alarm to sound and documentation on the code alert log and reporting. In addition, a form was created, Acknowledgement of Risks/Criteria: Being Outside Facility Unsupervised that will be presented to residents and/or their responsible parties. Policies reviewed: Missing Resident; Wandering and Elopement of Residents; Resident Tracking and Exits with Key Pads. A missing resident quiz was created for staff to complete during inservice training. 4. The Administrator received training by the Governing Body on 03/22/12 and 03/23/12 in response to the survey findings regarding supervision, wandering, elopement and reporting of incidents. The State Agency validated the AOC as follows: 1. The State agency validated documentation of education provided to staff which included policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads. The facility staff roster indicated there were one-hundred and fifty-five (155) staff and one-hundred and forty-two (142) had been educated by 03/24/12 on the policies and procedures. The facility provided documentation of a detailed plan to train the remainder of the staff prior to their date of return to work. 2. Interviews on 03/30/12 at 6:30 PM with five (5) CNA's, three (3) RN's, two (2) LPN's, one (1) dietary staff, and one (1) medical records staff revealed that all staff members were able to identify elopement and were knowledgable of reporting incidents. 3. Interview with the Administrator, on 03/30/12 at 10:50 AM, revealed he had received training in supervision, wandering residents, elopement-definition, and policies specific to the facility's needs. 4. The State Agency validated education of the Department Heads through interview with Staff Development, Activities, Medical Records, and Social Services, on 03/30/12 between 5:20 PM and 6:00 PM.

Based on observation, interview, record review, and review of the facility's policy on Wandering and Elopement of Residents and Resident Tracking, it was determined the facility failed to provide adequate supervision for one (1) of twenty (20) sampled residents for elopement and exit seeking behaviors. Resident #1 was assessed by the facility to be at high risk for elopement; was monitored with a Code Alert bracelet; and placed on fifteen (15) minute tracking to ensure the safety of the resident due to exit seeking behavior. On 01/31/12, Resident #1 exited through a Code Alert door without staff knowledge, then self-propelled in a wheelchair through the parking lot and onto the street in front of the facility (Boxwood Run Road). Resident #1 fell out of his/her wheelchair as an off duty staff member approached the resident on the street, and returned the resident to the facility. Resident #1 sustained no injuries. The facility's failure to provide adequate supervision placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/22/12 and was found to exist on 01/31/12. The facility provided a credible Allegation of Compliance (AOC) on 03/30/12. The State Agency verified Immediate Jeopardy was removed on 03/25/12 as alleged, prior to exit on 03/30/12; which lowered the scope and severity to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of implemented action plans to achieve and maintain compliance. The findings include: Review of the facility's policy regarding Wandering and Elopement of Residents, dated May 2010, detailed all residents would be assessed upon admission for elopement risks, quarterly, and as the need was determined. The policy also revealed a resident identified at risk for elopement would be identified in elopement binders on each unit, and would be assigned a Code Alert bracelet. The policy revealed the Director of Nursing (DON) or Administrator would notify the State Agency of an incident of elopement as required. However, the policy failed to define elopement. Review of the facility's policy regarding Resident Tracking, dated December 2011, revealed residents needing increased supervision were placed on fifteen (15) minute tracking, and the nurse was responsible to document the resident's "position" in fifteen (15) minute intervals, and all staff assigned to the resident were to be notified of the tracking function. Review of the clinical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. On 07/09/11, the facility assessed the resident at high risk for elopement related to cognitive deficit and exit seeking behavior. The Elopement Risk Assessments revealed the facility reassessed Resident #1 to be at high risk of elopement on 07/10/11, 10/12/11, 01/01/12, and 02/20/12. Resident #1 was care planned for wandering and exit seeking behavior and staff was to observe and document resident behaviors, and alert staff to wandering behaviors. The resident had a Code Alert bracelet to alert staff of an attempt to elope and the bracelet was to be checked for placement and function every shift. On 08/13/11, Resident #1 exited the facility, the Code Alert Alarm sounded, and the resident was returned to the facility from the parking lot. At that time Resident #1 was placed on and remained on fifteen (15) minute tracking. Review of the facility Event Report, dated 01/31/12 detailed that Resident #1 was outside at 1445 (2:45 PM) and the wheelchair fell over in a grassy area. The problem was identified on the Event Report as a witnessed fall, and the immediate facility intervention was to change the Code Alert bracelet, apply a new bracelet to the left ankle, add a bracelet to the wheelchair, and continue Resident #1 on fifteen (15) minute tracking. The Post Event Investigation described the type of event as a "Witnessed fall, resident outside, wheelchair noted to fall over," and the facility intervention was: "fifteen (15) minute tracking, Code Alert band on resident and wheelchair........" Review of the Morning Meeting Notes dated 02/01/12 and documented by the Administrator, revealed discussion of Resident #1 incident on 01/31/12 was described in terms of a "fall." Review of the investigation notes signed by the Administrator on 01/31/12, revealed the DA (Dietary Aide) told the Administrator when he parked in the lot at the end of Boxwood Run Road, he saw Resident #1 "wheeling self down Boxwood Run (Road) toward the Veterinarian Clinic (at the end of the road which intersected Highway 44)." The statement detailed how the wheelchair tilted off of the pavement as the DA approached Resident #1 and the resident fell out of the wheelchair onto the grass. The investigation documented the transponder for Resident #1 was tested (result of test was not documented) and two (2) new transponders were assigned to the resident, one (1) to the ankle and one (1) to the wheelchair. Interview, on 03/15/12 at 4:00 PM, by telephone, and on 03/20/12 at 8:20 AM, with the Dietary Aide (DA) revealed he left work at the end of his scheduled shift on 01/31/12 between 3:30 PM and 4:00 PM. The DA stated that he exited the building and went to his car in the lot behind the facility. As the DA was leaving the parking lot, he noticed a staff member who was pushing a male resident in a wheelchair. When the DA drove around the building to the front, he noticed Resident #1 in a wheelchair near the Physical Therapy entrance. The DA thought Resident #1 was with the staff member and male resident seen behind the building, until the DA noticed Resident #1 continued to self-propel in the wheelchair toward the street in front of the facility (Boxwood Run Road). The DA said Resident #1 was always in sight from the rear view mirror in the car, and said two (2) cars passed the resident in the wheelchair on Boxwood Run Road. The DA continued to drive to the end of Boxwood Run Road and parked. The DA said Resident #1 was moving fast toward Highway 44 which intersected with Boxwood Run Road. The DA moved toward Resident #1 to return the resident to the facility; however, upon his approach, a wheel to the chair went off of the pavement and the wheelchair rolled over. Resident #1 fell out of the wheelchair into a grassy area. The DA assisted Resident #1 to the wheelchair and returned the resident to the facility. The DA entered the facility through the Physical Therapy front entrance and did not hear an alarm sound when the resident was returned through the door. The DA said he showed the DON the location where Resident #1 slipped off of the pavement on Boxwood Run Road. Interview, on 03/16/12 at 1:35 PM, with the Staff Development Coordinator (SDC) revealed she was working on the Transitional Unit when the DA returned Resident #1 to the facility on [DATE]. The SDC reported the incident involving Resident #1 to the Administrator and DON and assigned the UM to perform a physical assessment. Further interview, with the SDC on 03/21/12 at 10:45 AM, revealed the SDC cut the Code Alert bracelet off of Resident #1 and took the bracelet to the employee entrance at the back of the building and checked the function of the Code Alert Alarm in the presence of the Maintenance Director. The SDC said the alarm sounded and she requested the Maintenance Director and the Assistant Maintenance Director to check the other three (3) Code Alert doors. The SDC was told all the Code Alert doors were functioning as a result of the cursory check. The SDC said the Code Alert band was not checked with the wand/checker from the medication cart because her first instinct was to cut the bracelet and check it with the Code Alarm doors. Interview, on 03/21/12 at 11:00 AM, with the Director of Nursing (DON) revealed that he was notified by the SDC that Resident #1 had exited the facility on 01/31/12 without supervision. The DON said he was not present when the Code Alert bracelet was removed from Resident #1. The DON said the SDC told him all four (4) Code Alert doors were checked with the bracelet removed from Resident #1 and the door alarms were found to be functional. The DON said he was told the bracelet had been thrown into the trash. However, since the bracelet was found to be functional, it was retrieved from the trash and placed on the wheelchair of Resident #1. A new Code Alert bracelet was applied to the resident's ankle. The DON said he interviewed the DA upon return of Resident #1 to the facility on [DATE], then walked outside of the facility and requested the DA to identify where the resident was seen self-propelling in the wheelchair. The DON said the DA showed him Resident #1 was on Boxwood Run Road. Interview, on 03/30/12 at 4:00 PM, with the Administrator revealed the Maintenance Director measured the distance from the main Physical Therapy entrance to the location where Resident #1 fell out of the wheelchair on Boxwood Run Road on 01/31/12. The Maintenance Director found the distance Resident #1 traveled in the wheelchair to be five- hundred and ten (510) feet. Interview, on 03/27/12 at 10:30 AM, with LPN #2 revealed she was the desk nurse working on the Transition Way Unit, which intersects with the therapy unit, on 01/31/12 . LPN #2 did not see Resident #1 attempt to enter the Physical Therapy Unit, and did not hear a Code Alert alarm on 01/31/12 when Resident #1 exited the facility. Interview, on 03/27/12 at 11:10 AM, with the Human Resources Director (HRD) revealed she was working on 01/31/12 when Resident #1 exited the facility. The HRD stated her office was next to the Code Alert door at the main entrance to the Physical Therapy door where the facility surmised Resident #1 exited on 01/31/12. The HRD said on that day, she did not hear an alarm from the Code Alert door, and stated if she heard an alarm, she would go to the Code Alert door immediately to determine the reason for the alarm. The HRD said the occurrence was to be reported to Nursing Administration and documented. Interview, on 03/16/12 at 2:50 PM, with Registered Nurse (RN) #1 revealed Resident #1 was seen by RN #1 self-propelling in the hall moving toward the main dining area (in front of the main entrance) at about 2:35 PM on 01/31/12. RN #1 did not hear a Code Alert Alarm as Resident #1 exited or re-entered the facility on 01/31/12. RN #1 did not know if Resident #1 had exited the facility before 01/31/12. Interview and observation, on 03/16/12 at 11:15 AM, with the Maintenance Director with a demonstration of the function of the Code Alert door, found that the Code Alert alarm would sound when a resident wearing a Code Alert transponder was within six (6) feet of the Code Alert door. The Maintenance Director said the DON requested him to check all of the Code Alert doors on 01/31/12, and he found the alarms on all four (4) Code Alert doors to be functioning. The Maintenance Director and the Assistant Maintenance Director said when Resident #1 exited the facility, it was not considered an elopement because a staff member was watching the resident and knew of the resident's location. Interview, on 03/16/12 at 1:00 PM, with the Unit Manager (UM) of Orchard Way, revealed that the facility had not experienced any "true elopements". The UM defined elopement as a resident who left the "facility property." The UM said as a result of Resident #1 exiting the facility on 01/31/12, fifteen minute tracking was continued for the resident. The UM was not aware of any further interventions to avoid elopement for Resident #1 since the resident exited the facility on 01/31/12. Continued interview, on 03/16/12 at 2:50 PM, with RN #1 revealed elopement was defined as a resident who was off of the facility grounds without someone supervising the resident. RN #1 said the facility added interventions to avoid future elopements, but was not sure what the interventions were, and did not remember any education or training of staff regarding elopement since Resident #1 exited the facility on 01/31/12. RN #1 said Resident #1 was at risk for injury when the resident was outside of the facility on 01/31/12. Continued interview, on 03/21/12 at 11:00 AM, with the Director of Nursing (DON) revealed elopement was described as unwitnessed or unsupervised exit of the property. The DON said he did not want to speculate about what potential hazards Resident #1 faced on Boxwood Run Road; however, when asked if Resident #1 could have been hit by a car, he replied, "That is a potential," because the DA was not in arms reach of Resident #1 while driving on Boxwood Run Road. The DON did not consider the exit from the facility by Resident #1 to be an elopement because the DA had eyes on the resident "the whole time." The DON said Resident #1 "was supervised, I know that." Interview, on 03/21/12 at 3:35 PM, with the Administrator revealed when Resident #1 exited the facility on 01/31/12 without staff supervision, the event was not considered an elopement, and therefore was not reported to the State Agency. The Administrator said he did not wish to label the event as an elopement and said he would only state that Resident #1 "was not witnessed crossing the threshold to exit the facility by anyone." The Administrator said he interviewed the DA and was told by the DA that Resident #1 was on the sidewalk when the wheelchair overturned with the resident. The Administrator said the DA showed the DON where Resident #1 was found, and he could not remember if the DON told him the resident had been on the sidewalk or on Boxwood Run Road when the DA reached the resident in the grass. The Administrator did not witness the function check of the Code Alert bracelet removed from Resident #1, but was told by the DON that the transponder was working. The Administrator said Resident #1 was at no greater risk of injury or accident outside of the facility in the parking lot, on the sidewalk, or on the street in front of the facility. Interview, on 03/16/12 at 11:30 AM, with the Administrator revealed the facility did not report any elopements since 05/2011. The Administrator stated "we have not had any elopements since May, 2011. We have had residents exit seeking and exit facility, but not any we considered elopements". Review of the Allegation of Compliance (AOC) revealed the facility took the following immediate actions: 1. Elopement assessments, which included the complete resident census of one-hundred three (103), were completed on 03/23/12. The facility determined thirteen (13) residents to be at risk for elopement. 2. The facility audited and revised the Certified Nursing Assistant (CNA) sheets on 03/23/12 for the thirteen (13) residents that were found to be a risk for elopement. 3. The facility educated the staff on 03/24/12 to include policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads including elopement definition and reporting. 4. The facility initiated Resident Tracking Sheets for the residents determined to require every fifteen minute checks. Staff are to document at fifteen (15) minute intervals at the time the resident is observed. 5. The facility closed the double doors between the Therapy Addition and Transition Way Unit and staff were directed to leave the doors closed. This door requires a coded entry. 6. The Director of Nurses and Maintenance Director checked all doors and alarms to ensure they were functioning properly. 7. The Unit Manager provided education to the staff on duty regarding every 15 minute checks. 8. Department Heads and Administrative staff were provided education and the facts of the incident by the Administrator on 03/22/12. 9. The elopement binder is to be reviewed weekly on Fridays by the Administrator to ensure the photographs and face sheets are in the binder. 10. The Resident Safety Policy was reviewed and revised with a new definition of elopement, response to alarms, checking the area around the alarm, determining the cause of the alarm to sound and documentation on the code alert log. In addition, a form was created, Acknowledgement of Risks/Criteria: Being Outside Facility Unsupervised that will be presented to residents and/or their responsible parties. Policies reviewed: Missing Resident; Wandering and Elopement of Residents; Resident Tracking and Exits with Key Pads. A missing resident quiz was created for staff to complete during inservice training. 11. The Administrator received training by the Governing Body on 03/22/12 and 03/23/12 in response to the survey findings including elopement and reporting of incidents. The State Agency validated the AOC as follows: 1. The State Agency validated documentation of elopement assessments which included the complete resident census of one-hundred three (103). The resident Elopement assessment scores were documented, and it was determined that thirteen (13) of one-hundred three (103) residents were at risk for elopement. The facility began the assessments on 03/22/12, and were completed on 03/23/12. It was verified on 03/30/12, that the facility reviewed and updated care plans for all thirteen (13) residents determined by the facility to be at risk for elopement. 2. The State Agency validated documentation of audits of audits of audits comparing CNS sheets to assessments and careplans and revisions to the Certified Nursing Assistant (CNA) sheets that was completed on 03/23/12 for the thirteen (13) residents that were found to be a risk for elopement. It was verified by review of all thirteen (13) CNA sheets for residents at risk for elopement, that the revisions were completed on 03/23/12. 3. The State Agency validated documentation of education provided to staff which included policies for: Wandering and Elopement of Residents, Resident Tracking, Missing Residents, and Exits and Key Pads. The facility staff roster indicated there were one-hundred and fifty-five (155) staff and one-hundred and forty-two (142) had been educated by 03/24/12 on the policies and procedures. The facility provided documentation of a detailed plan to train the remainder of the staff prior to their date of return to work. 4. The State Agency validated on 03/30/12, by observation of four (4) residents who were found to be at risk for elopement, that each resident had a Resident Tracking Sheet which accompanied each resident as they moved through the facility to Activities, Dining, etc. It was determined by observation, staff were documenting on the Resident Tracking Sheets in fifteen (15) minute intervals at the time of the resident observation. Interview with a staff member on 03/30/12 at 6:20 PM, revealed when a resident with fifteen (15) minute tracking moved to another area of the facility, documentation on the Resident Tracking sheet was completed by the staff member who accompanied the resident to that area. 5. Interviews on 03/30/12 at 6:30 PM with five (5) CNA's, three (3) RN's, two (2) LPN's, one (1) dietary staff, and one (1) medical records staff revealed that all staff members were able to state the steps staff was responsible for when a resident was missing, responsibilities of staff when a resident is on Resident Tracking, and a resident who wandered near a facility exit door. In addition, staff were able to identify elopement and were knowledgeable of reporting incidents. 6. Interview with the Administrator, on 03/30/12 at 10:50 AM, revealed he had received training in supervision, wandering residents, elopement-definition, and policies specific to the facility's needs. 7. The State Agency validated education of the Department Heads through interview with Staff Development, Activities, Medical Records, and Social Services, on 03/30/12 between 5:20 PM and 6:00 PM.

Based on interview, observations, record review and review of the facility's policy on Wandering and Elopement of Residents and Missing Residents it was determined the facility failed to supervise one (1) resident (#1) of the five (5) sampled residents for exit seeking behaviors. The facility identified Residents' #1, #2, #3, #4, and #5 at risk for elopement. The facility failed to ensure all exit doors were monitored during construction when the code alert alarm was removed from the front exit door. The facility staff was unaware Resident #1 exited the facility without supervision on 05/10/11. The facility's failure to provide adequate supervision placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident The facility provided an acceptable allegation of compliance (AOC) on 05/16/11. The state agency verified Immediate jeopardy was removed 05/16/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care, F323, and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors the effectiveness of the barriers and the new code alert system. The findings include: Review of the facility's policy regarding the Wandering and Elopement of Residents, dated 05/10, indicated precautions will be initiated for the residents determined to be at risk for elopement. All residents will be assessed, if at risk will be assigned a code alert bracelet, information placed in the elopement binder, and reviewed by the careplan team. Review of the facility's policy on the Missing Resident, dated 03/09, indicated if a resident is unaccounted for or missing a search would be initiated. The facility and grounds will be searched and if not found 911 will be called. Interview, on 05/13/11 at 2:40pm, with the Director of Nursing (DON) revealed when construction started there was a plywood wall from the floor to the ceiling. It had no access except by the construction crew through the front door. The temporary wall was removed on 05/10/11 at 3:00pm. The cones and caution tape were placed at each end of the lobby to block the hallway. Prior to construction the DON met with the supervisors regarding the renovations and told them to keep an eye on the residents. However, direct care staff was not given any instruction on increased supervision. Interview, on 05/13/11 at 3:30pm, with LPN #2 revealed the lobby had a temporary wall and she was not informed the wall had been removed. There were only cones and caution tape. However, you could still get to the door and it was unlocked. An employee was placed in the area at this point until maintenance could secure the area. She did not receive instruction to increase supervision when the wall was taken down. Interview, on 05/14/11 at 12:54pm, with CNA #1 revealed she did not receive any instruction regarding the wandering residents need for increased supervision when the barrier wall was taken down. Interview, on 05/16/11 at 1:40pm, with CNA #2 revealed she did not receive any instruction on increased monitoring of the wanderings residents only to keep more alert with the construction going on. Review of the clinical record for Resident #1 revealed the facility admitted the resident on 09/14/10 with [DIAGNOSES REDACTED]. On 11/10/10, the facility assessed the resident as a high risk for elopement related to cognitive deficit and exit seeking behavior. The facility reassessed the resident on 03/01/11 and 05/10/11 at high risk for elopement. The facility care planned the resident for wandering and exit seeking behaviors and staff were to monitor the resident specifically during periods of anxiety dated 05/10/11. The resident was further care planned to have a code alert to alert staff of attempts to elope and check every shift for placement dated 01/06/11. Review of the facility's investigation, dated 05/11/11, revealed Resident #1 eloped from the facility on 05/10/11. A facility staff member reported observing the resident walking on the sidewalk of a busy street. This staff member stayed with the resident until the facility was notified the resident was gone. Construction was currently taking place to the surrounding exit and the door with the code alert system had been removed leaving a non-code alert door accessible for exit. Interview, on 05/13/11 at 2:30pm, with LPN #4 revealed she was traveling east on Hwy. 44, and looked back at the facility, when she saw Resident #1 on the sidewalk. She turned around to get the resident at 7:50pm. The resident was taken back to the facility. The LPN stated the facility did not instruct her to increase supervision of the wandering residents when the construction was started or to monitor the front door when the barrier wall was taken down. It was known by all staff that Resident #1 frequently walked the halls and would exit seek. Interview, on 05/13/11 at 3:07pm, with LPN #3 revealed she was the supervisor on the evening shift of 05/10/11. When the resident was brought back to the facility, the code alert bracelet sounded upon entering the door to the transition unit. All doors were checked and were working except for the front door. It was found to be accessible to the outside by just opening the door. LPN #3 stated she last saw the resident at 7:00pm and talked about going to bed. The resident then headed towards his/her room away from the construction site. LPN #3 felt the area was secure until the wall came down. She found one wandering resident lifting the caution tape and they were redirected away. Resident #1 walked up to the tape and was redirected using the detour around the construction site. LPN #3 stated no one saw the resident after 7:00pm. In addition, usually another nursing assistant or the nurses watch the residents while a staff member is at meal break; however, this was not done if the resident managed to get out of the building. Interview, on 05/13/11 at 3:30pm, with LPN #2 revealed around 8:00pm a man came in and said a resident was out on Hwy 44. She left the building and a nursing assistant was coming behind her with a wheelchair. She found an off duty employee walking the resident back towards the facility. All the doors were checked because the alarm sounded when the resident re-entered the facility. She did not hear an alarm sound before this. The front door did not have an alarm, otherwise it would have sounded until someone turned it off. Interview, on 05/13/11 at 1:44pm, with LPN #5 revealed when the resident's alarm sounds, the staff are to respond by following the sound to see who needs help. Interview, on 05/13/11 at 3:40pm, with LPN #1 revealed she worked as a nursing assistant that evening and not assigned to the group for Resident #1. She further stated she saw the resident between 5:30pm and 6:00pm and spoke to him/her. However, never checked on the location of the resident afterwards. Interview, on 05/14/11 at 12:54pm, with CNA #1 revealed she saw the resident in the dining room at supper time. The resident was seen leaving the dining room around 6:10pm. This CNA went on her meal break and when she returned proceeded to put residents to bed. She did not check on the location of Resident #1 until instructed by a nurse to help locate the resident. Review of the investigative report dated 05/10/11 and interview with the Director of Nursing on 05/13/11 at 2:40pm and the Administrator on 05/16/11 at 1:10pm revealed the facility took the following immediate action: 1. The facility performed a physical assessment on Resident #1 and found no injuries. 2. Resident #1 was placed on every 15 minute checks until the new code alert system was installed on the front door. 3. An employee was stationed at the front entrance to monitor any resident activity. 4. All alarmed doors were checked. 5. All code alert bracelets were checked. 6. The maintenance department installed a rigid barrier to prevent access to the construction site. 7. The barriers were placed on every 30 minute checks to ensure they were intact. Additional measures were taken on 05/11/11: 1. Review of all residents identified as at risk for elopement to ensure supervision of their activities. 2. All alarmed doors were placed on weekly checks by maintenance and every shift checks by nursing when checking the code alert bracelets. 3. Elopement binders were reviewed, pictures and demographic information placed in binders for four (4) residents and placed at new reception area. 4. Reviewed policy and procedures regarding wandering residents, elopement and missing residents for revisions. 5. Education of all staff regarding the wandering resident, elopement and missing resident 05/10/11, 05/12/11, 05/13/11, 05/14/11 and 05/15/11. 6. Education of the construction crew on 05/16/11 regarding the barriers are to remain in place until the construction is completed or code alert system is installed at the front door. Observation, on 05/16/11 at 11:30am, revealed Resident #1 sitting in the dining room at the table with other male residents. A code alert bracelet was noted on the right ankle. At 1:10pm the resident was in his/her room a code alert bracelet remained on the right ankle. Review of the clinical record for Resident #2, #3, #4 and #5 during the survey revealed the residents had been assessed for risk for elopement and had code alert bracelets on. Resident #5 was reassessed on 05/10/11 by the facility as improved and no longer required the code alert bracelet. Resident #5 was removed from the elopement binder. Resident's #2, #3, #4 and #5 had not eloped from the building. Interview with the Administrator on 05/16/11 at 1:10pm revealed informal meetings every morning had been held with staff to discuss the cause and action plan related to the elopement of Resident #1. A formal QA meeting would be held on Thursday 05/19/11. On 05/13/11 at 10:30am a check of all the alarmed doors (3) completed with the Director of Nurses revealed all checks had been completed and the alarms were functional. Validation of staff training May 10 - 15, 2011 via sign-in rosters revealed all staff attended with the exception of one, who was currently in the hospital. This staff person will receive training, prior to being assigned to work with the residents. Observations of the front lobby area, on 05/13/11 at 10:15am, revealed a construction site with four foot (4ft.) tall cones and caution tape draped between them. Directly behind these were four foot by eight foot (4x8 ft) barriers on either side of the lobby blocking the hallways and entrance to the construction site. Observations of Resident #1, on 05/13/11 at 11:05am, 11:27am, 1:20pm and on 05/16/11 at 11:30am and 1:10pm revealed the resident had a code alert bracelet applied to the ankle, in his/her room or in the dining room. Immediate Jeopardy was verified to be removed prior to exit on 05/16/11 with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care, F323, and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors the effectiveness of the barriers and the new code alert system.

Based on record review, observation and interview, it was determined the facility failed to follow the plan of care for one resident (#1) of the five (5) sampled residents. Resident #1 was careplanned to be monitored due to cognitive deficit and exit seeking behaviors. The facility failed to monitor the location of Resident #1 during construction of the front lobby. The resident exited the front entrance door without staff knowledge. The facility remained unaware of the residents location, until a citizen alerted the facility that the resident was found on the sidewalk of a busy street. The facility's failure to follow the plan of care placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident The facility provided a credible allegation of compliance (AOC) on 05/16/11. The state agency verified Immediate jeopardy was removed 05/16/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care, F323, and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors the effectiveness of the barriers and the new code alert system. The findings include: The facility did not provide a policy on following the plan of care. Review of the clinical record revealed the facility admitted Resident #1 on 09/14/10 with [DIAGNOSES REDACTED]. On 09/27/10, the facility developed a plan of care for Wandering, Socially inappropriate at times, and exit seeking behaviors. The facility implemented interventions for staff to: 1. place monitoring device on resident that sounds alarms when resident leaves building; 2. alert staff to resident's wandering behavior; and 3. note which exits resident favors for elopement from facility. Alert staff working near those areas. The facility implemented a code alert device and placed the device on the resident's ankle to alert facility staff should the resident attempt to exit the facility without staff knowledge. On 11/10/10, the facility reassessed Resident #1 as at high risk for elopement related to the resident's impaired cognition and exit seeking behaviors. Observations of Resident #1 on 05/13/11 at 11:05am, 11:27am, 1:20pm and on 05/16/11 at 11:30am and 1:10pm revealed the resident with a code alert bracelet to the ankle. The nursing staff were noted to be checking the resident's location and responding to the alarms. Interview, on 05/13/11 at 1:44pm, with LPN #5 revealed when the alarms sound, staff respond by following the sound, to see who needed help. Interview, on 05/13/11 at 2:30pm, with LPN #4 revealed the facility did not instruct her to increase supervision of the wandering residents when the construction was started or to monitor the front door when the barrier wall was taken down. It was known by all staff that Resident #1 frequently walked the halls and would exit seek. Interview, on 05/13/11 at 3:07pm, with LPN #3 revealed the staff were to monitor Resident #1 due to wandering all over the facility according to the care plan. She last saw the resident at 7:00pm and thought the resident was going to his/her room. While the assigned nursing assistant was at dinner, the other staff on the unit were to monitor the resident. She indicated all staff are responsible for monitoring the wandering residents. Interview, on 05/13/11 at 3:30pm, with LPN #2 revealed she monitored the wandering resident through the elopement binder and code alert checks done every shift. She assumed the supervision of wandering residents would be increased due to the construction; however, she never received any direction regarding this. Interview, on 05/13/11 at 3:40pm, with LPN #1 revealed although she was an LPN she was working as a nursing assistant that night. Resident #1 was not in her assigned group; however, she did see the resident between 5:30 and 6:00pm. She did not run into the resident again and thought the resident was in his/her room; however, she did not check to see where the resident was. Interview, on 05/14/11 at 12:54pm, with CNA #1 revealed she had gone to her dinner after helping in the dining room. During the meal she saw Resident #1 sitting in the dining room. At 6:10pm the resident was seen leaving the dining room. She came back from dinner at 6:45pm and started to put other residents to bed. She did not check where Resident #1 was until a nurse instructed her to help look for the resident. Interview, on 05/16/11 at 1:40pm, with CNA #2 revealed she monitored wandering residents by redirecting them back to their unit or calling the unit to come and get the resident. However, she did not remember if Resident #1 had been on her unit that evening and did not check on the resident until a visitor came to the facility and informed her the resident was outside. Review of the investigative report dated 05/10/11 and interview with the Director of Nursing on 05/13/11 at 2:40pm and the Administrator on 05/16/11 at 1:10pm revealed the facility took the following immediate action: 1. The facility performed a physical assessment on Resident #1 and found no injuries. 2. Resident #1 was placed on every 15 minute checks until the new code alert system was installed on the front door. 3. An employee was stationed at the front entrance to monitor any resident activity. 4. All alarmed doors were checked. 5. All code alert bracelets were checked. 6. The maintenance department installed a rigid barrier to prevent access to the construction site. 7. The barriers were placed on every 30 minute checks to ensure they were intact. Additional measures were taken on 05/11/11: 1. Review of all residents identified as at risk for elopement to ensure supervision of their activities. 2. All alarmed doors were placed on weekly checks by maintenance and every shift checks by nursing when checking the code alert bracelets. 3. Elopement binders were reviewed, pictures and demographic information placed in binders for four (4) residents and placed at the new reception area. 4. Reviewed policy and procedures regarding wandering residents, elopement and missing residents for revisions. 5. Education of all staff regarding the wandering resident, elopement and missing resident 05/10/11, 05/12/11, 05/13/11, 05/14/11 and 05/15/11. 6. Education of the construction crew on 05/16/11 regarding the barriers were to remain in place until the construction was completed or code alert system was installed at the front door. Observation, on 05/16/11 at 11:30am, revealed Resident #1 sitting in the dining room at the table with other male residents. A code alert bracelet was noted on the right ankle. At 1:10pm the resident was in his/her room a code alert bracelet remained on the right ankle. Review of the clinical record for Resident #2, #3, #4 and #5 during the survey revealed the residents had been assessed for risk for elopement and had code alert bracelets on. Resident #5 was reassessed on 05/10/11 by the facility as improved and no longer required the code alert bracelet. Resident #5 was removed from the elopement binder. Resident's #2, #3, #4 and #5 had not eloped from the building. Interview with the Administrator on 05/16/11 at 1:10pm revealed informal meetings every morning had been held with staff to discuss the cause and action plan related to the elopement of Resident #1. A formal QA meeting would be held on Thursday 05/19/11. On 05/13/11 at 10:30am a check of all the alarmed doors (3) completed with the Director of Nurses revealed all checks had been completed and the alarms were functional. Validation of staff training May 10 - 15, 2011 via sign-in rosters revealed all staff attended with the exception of one, who was currently in the hospital. This staff person will receive training, prior to being assigned to work with the residents. Immediate Jeopardy was verified to be removed prior to exit on 05/16/11 with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care, F323, and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors the effectiveness of the barriers and the new code alert system.

Based on interview and record review of the facility's investigation, it was determined, the facility failed to ensure a safety plan was in place during the construction of the front lobby to prevent the elopement of one (1) resident (#1) of the five (5) sampled residents. Resident #1 eloped from the facility after a temporary wall was removed that prevented access to the construction site by the wandering residents. The exit door was not secured when the code alert system was removed and no measures were put in place to prevent the wandering residents from exiting the front door. The facility's failure to ensure a safety plan was in place during the construction phase placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident The facility provided a credible allegation of compliance (AOC) on 05/16/11. The state agency verified Immediate Jeopardy was removed 05/16/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care, F323, and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors the effectiveness of the barriers and the new code alert system. The findings include: Record review of the facility's investigation for elopement revealed Resident #1 exited the building on 05/10/11 sometime between 7:00pm and 8:00pm without staff knowledge. The resident was found ambulating on the sidewalk of a busy street by a staff member who was off duty. The facility was notified and the resident was returned to the facility. Interview, on 05/13/11 at 2:40pm, with the Director of Nursing (DON) revealed the direct care staff were not given any direction/instruction to increase supervision of the wandering residents when the barrier wall was taken down. It was the responsibility of the DON and Administrator to ensure the safety of the residents during construction. Additionally, it was the responsibility of the DON and Administrator to inform the construction crew of the potential dangers for the wandering residents if equipment was left lying around and exit doors were left open and unattended. The construction crew was not made aware of this by him. Interview, on 05/16/11 at 11:10am, with the Maintenance Director revealed the construction area was contained with a temporary wall. On 05/10/11 at 3:00pm the temporary wall was taken out due to trim work needed to be done. The cones and caution tape hade always been there and were put there by the construction crew. In addition, the crew were told they would be held accountable for locking the front door when they left for the evening. However, the front door could be opened from the inside even if it was locked. Nothing was put in place by the facility to prevent the residents from going out the front door in the construction area. The Maintenance Director felt it was overlooked by everyone. Interview, on 05/16/11 at 1:10pm, with the Administrator revealed the temporary wall was erected when the alarm system was removed with the front door. The wall was removed on 05/10/11. The cones and caution tape were left in place; however, no other safety measures were put in place to prevent the wandering residents from entering the construction site. The Administrator stated he did not know how, but he never thought of the immediate danger for the residents when the wall was removed. He indicated there was a safety meeting held with the construction supervisor. However, no check list or safety system was utilized to ensure the site was secure at all times once the wall was taken down. Review of the investigative report dated 05/10/11 and interview with the Director of Nursing on 05/13/11 at 2:40pm and the Administrator on 05/16/11 at 1:10pm revealed the facility took the following immediate action: 1. The facility performed a physical assessment on Resident #1 and found no injuries. 2. Resident #1 was placed on every 15 minute checks until the new code alert system was installed on the front door. 3. An employee was stationed at the front entrance to monitor any resident activity. 4. All alarmed doors were checked. 5. All code alert bracelets were checked. 6. The maintenance department installed a rigid barrier to prevent access to the construction site. 7. The barriers were placed on every 30 minute checks to ensure they were intact. Additional measures were taken on 05/11/11: 1. Review of all residents identified as at risk for elopement to ensure supervision of their activities. 2. All alarmed doors were placed on weekly checks by maintenance and every shift checks by nursing when checking the code alert bracelets. 3. Elopement binders were reviewed, pictures and demographic information placed in binders for four (4) residents and placed at new reception area. 4. Reviewed policy and procedures regarding wandering residents, elopement and missing residents for revisions. 5. Education of all staff regarding the wandering resident, elopement and missing resident 05/10/11, 05/12/11, 05/13/11, 05/14/11 and 05/15/11. 6. Education of the construction crew on 05/16/11 regarding the barriers were to remain in place until the construction was completed or code alert system was installed at the front door. Observation, on 05/16/11 at 11:30am, revealed Resident #1 sitting in the dining room at the table with other male residents. A code alert bracelet was noted on the right ankle. At 1:10pm the resident was in his/her room a code alert bracelet remained on the right ankle. Review of the clinical record for Resident #2, #3, #4 and #5 during the survey revealed the residents had been assessed for risk for elopement and had code alert bracelets on. Resident #5 was reassessed on 05/10/11 by the facility as improved and no longer required the code alert bracelet. Resident #5 was removed from the elopement binder. Resident's #2, #3, #4 and #5 had not eloped from the building. Interview with the Administrator on 05/16/11 at 1:10pm revealed informal meetings every morning had been held with staff to discuss the cause and action plan related to the elopement of Resident #1. A formal QA meeting would be held on Thursday 05/19/11. On 05/13/11 at 10:30am a check of all the alarmed doors (3) completed with the Director of Nurses revealed all checks had been completed and the alarms were functional. Validation of staff training May 10 - 15, 2011 via sign-in rosters revealed all staff attended with the exception of one, who was currently in the hospital. This staff person will receive training, prior to being assigned to work with the residents. Immediate Jeopardy was verified to be removed prior to exit on 05/16/11 with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F282, 42 CFR 483.25 Quality of Care, F323, and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors the effectiveness of the barriers and the new code alert system.