Every finding on record at Hardinsburg Nursing and Rehabilitation Center

Based on interview, record review, and review of facility document and policy, the facility failed to report an allegation of sexual abuse to the State Survey Agency (SSA) within 2 hours for 1 of 1 sampled resident reviewed for abuse, Resident(R)36. The findings include:Review of the facility policy titled, Abuse Prohibition Standard of Practice, revised 07/2022, indicated Alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames.Review of R36's admission Face Sheet revealed the facility admitted the resident on 11/05/2024. According to the admission Face Sheet, R36 had a medical history that included a diagnosis of severe vascular dementia with anxiety and mood disturbance.Review of R36's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/11/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment.Review of the facility Initial Report, indicated on 01/11/2025, R36 told a family member (FM)1 that during the night on 01/10/2025, two males entered the room and touched R36's breast. Per the Initial Report, facility staff became aware of the allegation on 01/11/2025 at 9:00 AM and the Administrator was notified on 01/11/2025 at 9:20 AM. An email to the SSA revealed the Director of Nursing (DON) sent the initial report regarding R36 on 01/11/2025 at 1:01 PM, approximately four hours after the facility was notified of the allegation.During a telephone interview on 07/08/2025 at 11:22 AM, FM1 stated, on 11/11/2025 when they visited R36, the resident stated a man entered the room and touched R36's breast. Per interview, FM1 reported the allegation to Certified Nursing Assistant (CNA)4. During an interview on 07/08/2025 at 12:00 PM, Kentucky Medication Aide (KMA)5 stated R36's FM reported the allegation of sexual abuse to her between 7:45 AM and 8:15 AM on 01/11/2025. KMA5 stated she then reported the allegation to Licensed Practical Nurse (LPN)6.During a telephone interview on 07/08/2025 at 2:08 PM, LPN6 stated, during shift change, R36's FM notified her R36 alleged a male had been in R36's room on 01/10/2025 and touched R36 inappropriately. LPN6 stated she immediately reported the incident to the Administrator and DON.During an interview on 07/09/2025 at 3:31 PM, the DON stated one of the nurses called her on 01/11/2025, when the allegation was reported, but she was unsure of the time. According to the DON, when an allegation of abuse was received there was a time limit of 24 hours to report to the SSA.During a follow-up interview on 07/10/2025 at 10:15 AM, the DON stated she was under the assumption that if there was no injury involved in an allegation, the facility had 24 hours to report the allegation to the SSA. The DON stated she now understood the facility reported the allegation of sexual abuse to the SSA late related to R36.During an interview on 07/09/2025 at 4:30 PM, the Administrator stated an allegation of abuse, to his understanding, had to be reported within two hours.During a follow-up interview on 07/10/2025 at 11:36 AM, the Administrator stated he and the DON were responsible for submission of reports to the SSA, but before they submitted the report, he had to send the report to the corporate office for review. The Administrator stated the report for the allegation of sexual abuse related to R36 was submitted late to the SSA.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the environment was free of accident hazards for 1 of 2 sampled residents reviewed for accidents, Resident (R)39. Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the environment was free of accident hazards for 1 of 2 sampled residents reviewed for accidents, Resident (R)39.FindingsCollapse[NAME]'s FindingsWriting Complete | Last Updated by [NAME] 07/25/2025 12:01 PM | The findings include: Review of the facility policy titled, Medication Administration Standard of Practice, dated 10/2020, revealed, Medications will be administered in a safe and timely manner, and as prescribed. Review of R39's admission Face Sheet indicated the facility admitted the resident on 11/26/2024. According to the admission Face Sheet, the resident had a medical history that included a diagnosis of low back pain. Review of R39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had occasional pain. Review of R39's Care Plan, included a problem area dated 06/26/2025, that indicated the resident had a recent surgery and had an incision. Interventions directed staff to administer medication as ordered, monitor effectiveness, and encourage the resident to verbalize the need for pain medication and/or pain-relieving measures (initiated 06/26/2025). Review of R39's Physician's Order Form for orders as of 07/09/2025, revealed an order started on 06/20/2025, for acetaminophen (Tylenol) 325 milligrams (mg) (medication used to treat mild to moderate pain), one tablet by mouth every four hours as needed, not to exceed 3,000 mg daily from all sources. There was no documented evidence of an order to keep the medication at the resident's bedside. During an observation on 07/07/2025 at 11:00 AM, a bottle of Tylenol 500 mg and a tube of cream was observed at R39's bedside. During an observation on 07/08/2025 at 1:10 PM, a one-ounce tube of bacitracin zinc ointment (a medication used on the skin to prevent infection) and a bottle of Tylenol 500 mg was observed on R39's bedside table. During an interview on 07/08/2025 at 1:10 PM, R39, stated the Tylenol and bacitracin zinc ointment was brought to the facility upon admission after a medical appointment with the urologist, approximately two to three weeks prior to 07/08/2025. Further interview revealed R39 applied the ointment and took two to four Tylenol from the bottle, daily, as needed without staff monitoring. R39 stated staff had not talked about the resident self- administering the medications, and R39 did not think Tylenol was a medication the nurse had to monitor. R39 opened the Tylenol bottle and stated there were six pills left in the bottle. During an observation on 07/09/2025 at 9:40 AM, Tylenol and bacitracin zinc continued to be on R39's bedside table. During an interview on 07/09/2025 at 10:12 AM, Registered Nurse (RN) 1 stated, Tylenol nor any type of ointment should be left at a resident's bedside without a doctor's order and an assessment to determine whether it was safe to leave medications at the bedside. Per RN1, if the resident had a Tylenol limit, it would be hard to monitor the amount the resident took if the resident had Tylenol at the bedside. During an interview on 07/09/2025 at 3:16 PM, the Director of Nursing (DON) stated she expected staff to report if there were any medications at a resident's bedside. The DON stated Tylenol usage should be monitored for side effects and if a resident wanted to self-administer a medication, the facility needed to conduct an assessment and speak to the doctor. During an interview on 07/09/2025 at 3:39 PM, the Administrator stated he expected staff to notify the nurse if they saw any medications at a resident's bedside.

Based on observation, interview, and record review, the facility failed to follow physician's orders for the administration of supplemental oxygen for 1 of 3 sampled residents reviewed for respiratory care, Resident (R)9. The findings include: Review of R9's admission Face Sheet revealed the facility admitted the resident on 05/02/2025. According to the admission Face Sheet, the resident had a medical history that included diagnoses of heart failure and pulmonary hypertension. Review of R9's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2025, revealed the facility assessed R9 as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Review of R9's Care Plan indicated a problem area initiated 05/26/2025, revealing the resident had a self-care deficit as evidenced by the need for moderate assistance with activities of daily living due to chronic obstructive pulmonary disease, diabetes, and generalized weakness. Interventions directed staff to give supplemental oxygen as ordered (initiated 05/26/2025). Review of R9's Physician Order Form for active orders as of 07/08/2025, revealed an order started on 05/04/2025, for supplemental oxygen at 2 liters per minute (LPM) per nasal cannula (NC) every shift. During an observation on 07/07/2025 at 10:55 AM, R9 was lying in bed with supplemental oxygen per NC. The supplemental oxygen concentrator flow rate was observed to be set at 3 LPM. During an interview on 07/09/2025 at 10:26 AM, Licensed Practical Nurse (LPN)2 stated it was the responsibility of the nurse to make sure a resident's supplemental oxygen concentrator was set at the LPM prescribed by the physician. LPN2 stated if the supplemental oxygen was set too high, the resident could retain too much carbon dioxide. LPN2 further stated R9's supplemental oxygen concentrator was set at 3 LPM. LPN2 reviewed the resident's physician orders and stated R9 should receive supplemental oxygen at 2 LPM by way of a NC. LPN2 stated she was unsure why the resident's supplemental oxygen was set at 3 LPM. During an interview on 07/10/2025 at 9:23 AM, the Director of Nursing (DON) stated the facility did not have a policy for oxygen administration. During an interview on 07/10/2025 at 11:12 AM, R9 stated staff had not adjusted the flow rate on the oxygen concentrator. R9 stated, I don't know nothing about that thing. During an interview on 07/10/2025 at 1:51 PM, the Staff Development Coordinator (SDC) stated supplemental oxygen initiation and oxygen flow rate adjustment were included in the nurses' competencies. The SDC stated she taught each staff member, documentation should be made in real time as much as possible and before checking the box on the Medication Administration Record (MAR), the nurse was expected to verify the oxygen flow rate. During a follow-up interview on 07/09/2025 at 3:03 PM, the DON stated the nurses were expected to check the resident's supplemental oxygen setting every shift and document the accuracy of the LPM on the MAR. The DON stated she expected the nurses to follow the physician's orders, and if the resident had a change in condition that required the resident's supplemental oxygen to be increased, she expected the nurse to call the physician to obtain a new supplemental oxygen order. During an interview on 07/10/2025 at 10:38 AM, the Medical Director stated he expected the nurses to monitor the residents' supplemental oxygen concentrator to ensure it was on the correct flow rate. The Medical Director stated it was important residents receive supplemental oxygen based on the order, because if the supplemental oxygen was not set as ordered the resident could become hypoxic (insufficient oxygen in the body). During an interview on 07/10/2025 at 11:32 AM, the Administrator stated he expected the nurses to follow orders from the physician for supplemental oxygen administration. The Administrator stated if the wrong amount of supplemental oxygen was delivered, the resident could become dependent upon the increased amount. The Administrator stated he was unsure whether R9 could change the supplemental oxygen setting and he had received no reports about the resident adjusting their flow rate.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food in a sanitary manner and in accordance with professional standards for food service safety. The sanitation handwashing area, sanitation prep sink area, and flooring were dirty/soiled and in need of cleaning. Dry spices, as well as food stored in the refrigerator and freezer were open and unsealed, unlabeled, undated, and/or past their expiration date. Scoops used for serving food were dirty with old food particles dried to them. Staff were not trained and/or were unaware of food storage requirements. This failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen. The findings include: Review of the facility's [NAME] Report, last updated [DATE], revealed 59 of 59 residents received their food from the kitchen. 1. Review of the facility's Environment policy, dated ,d+[DATE], revealed the purpose of the policy was to ensure that all food service areas would be maintained in a clean and sanitary condition. Per the policy, the Food Service Director would ensure that the physical plant would be maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation; all employees would be knowledgeable in the proper procedures for cleaning all food services equipment and surfaces; and all food surfaces were to be cleaned and sanitized after each use. Further, per the policy, the Food Service Director would ensure that a routine cleaning schedule was in place for all cooking equipment, food storage areas, surfaces, and floors. Review of the undated Daily Opening/Closing Duties and Check List revealed the opening/closing dietary staff was to ensure equipment such as the toaster and robot coupe (food processor) were clean, and the sink was cleaned and drained. Further dietary duties included sweeping the floors and under all equipment were to be swept and mopped at the beginning and end of each AM (morning) and PM (night) shift. a. Observation during the initial kitchen tour, on [DATE] at 10:08 AM, revealed the sanitation handwashing area of the sink, and back wash was dirty with stains, hair particles, noticeable dirt and buildup around the faucet and handles. Observation of the sanitation prep sink station and surrounding counter surfaces, including the window seal above the sink and counter, revealed spatter stains, dirt with debris buildup, dust, and food particles. b. Observation during the initial kitchen tour on [DATE] at 10:08 AM of the Food/Utensil Storage Drawer revealed three different sized scoops that were dirty with dried, old food particles stuck to the scoop and handles. c. Further observation on [DATE] at 11:25 AM, during tray line service, revealed the gas stove, the flat top grill, and the toaster were full of dried crumbs and food particles. The robot coupe and the remote pull station had thick oil and grease buildup on the top, sides, and front surfaces of the cooking equipment. Continued observation revealed a block of used, unrefrigerated melted butter on the countertop of the prep station with no label/date as well as a four (4) inch food stained, dirty blade knife on top of the butter case. The tile flooring in front, under, and around the sides of the stove/grill/toaster stations had thick greasy soil buildup and debris as well as old, dried macaroni noodles on the floor. Review of the Dietary's Daily Opening/Closing Duties and Check List for the month of [DATE], revealed no dietary staff initials were noted for the performance of different cleaning areas, only a down arrow for all the areas as well as no clean/check/log of dietary staff performance initials for any of the cleaning areas on [DATE], [DATE] and [DATE]. During interview on [DATE] at 10:20 AM, with the Dietary Manager (DM), she stated the sink was to be cleaned throughout the day on both shifts with the expectation that the sink would be white upon cleaning. However, DM was not able to convey a clear cleaning schedule for the handwashing area and stated that due to its appearance, the DM felt it had not been cleaned per the facility's cleaning schedule. The DM asked Dietary Aide (DA) 1 during the survey team's observation of the kitchen as to when the last time she had cleaned the handwashing station, and DA1 stated not since yesterday morning. 2. Review of the facility's Food Storage: Cold Foods policy, revised ,d+[DATE], revealed all food items would be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the undated Daily Opening/Closing Duties and Check List revealed dietary staff to check and ensure all food was labeled, dated, and checked for expiration date. In addition, daily duties of opening/closing dietary staff included ensuring all reach-in and walk-in refrigerators were clean, orderly, and checked for proper food storage. Observation during the initial tour of the kitchen conducted on [DATE] at 10:08 AM revealed foods were stored open and unsealed, unlabeled, undated and/or past their expiration date. Observations included: a. The dried seasoning station contained five plastic containers of 16-ounce unlabeled/undated seasonings which expired in 2020. b. Refrigerator 1 contained seven yogurt cups that were undated and without labels. c. Refrigerator 2 contained 10 bags of six cooked boiled eggs with a date of [DATE]; however, no discard date was noted on the label. One box of 15 cartons of liquid egg whites with citric acid was dated [DATE] and showed an [DATE] expiration date. One 30-ounce open jar of grape jelly had an expiration date of [DATE]. d. Refrigerator 3 contained one box of dietary supplemental shakes with a digital expiration date of [DATE] and no open/discard date and/or label. e. Freezer 1 contained one large, sealed bag of frozen chicken breasts, and an opened, unsealed large frozen bag of 11 freezer- burned country fried steaks. There was no open/discard date and/or label on either the chicken breast or country fried streaks. Interview on [DATE] at 11:00 AM with the DM revealed the refrigerators were to be checked one to two times daily per the dietary staff; however, she was unsure of the policy for how long the food items were held after being opened and/or how long it could be kept before disposal. 3. During an interview on [DATE] at 1:15 PM with DA1, she stated she had worked in the kitchen since ,d+[DATE], and her tasks included preparing desserts, drink cart and assisting the cook when her tasks were completed. When asked about training provided by the facility related to sanitation of the kitchen, she stated it had been done yesterday (after the survey had been initiated), but until then, there had been no training. She stated the 30-minute training and posttest taken the previous day covered steps to take with sanitizing the kitchen and cook area including dating the sanitation bucket and using strips to assure the mix was correct. She stated the solution for the sanitation bucket was premixed. DA1 added it was important to sanitize the kitchen area, as well as the handwashing station to prevent residents and staff from getting sick and to prevent cross contamination. DA1 also stated the training she received the previous day yesterday covered labeling of food. She stated the training stated to throw out leftovers after three days, and prior to the training, she thought the leftovers were kept longer but was unable to say for sure. When asked why it was important to discard leftovers in a timely manner and per labeling, she stated to prevent people from getting sick. She added the training included the need to note the throw away (discard) date of food. During an interview on [DATE] at 2:00 PM, with DA2, stated she would have worked at facility for one year in August. She stated she received sanitation training for the kitchen area by her previous boss when she first started but had not received any training since. She stated training was provided yesterday (after the above-noted observations were made by the survey team) and added she received her food handlers license at that time. She stated during her previous training, she had shadowed another kitchen staff for a couple of days. She stated the old training covered labeling and storage and used the seven-day rule. When asked what that meant, she stated when something was opened, it was labeled to throw away in seven days. She stated she was unsure which foods were to be discarded after the seven days though, but thought milk was one of them. When asked about sanitation of the kitchen area she stated the cleaning solution was placed in a red bucket to sanitize the tables and all surfaces in the kitchen adding there was a green bucket, but she was unsure the purpose of it. DA2 added the importance of sanitizing the kitchen area was to prevent cross contamination to prevent people from getting sick. She stated labeling and to follow labeling was important to prevent Salmonella and pests in the kitchen. Interview on [DATE] at 10:08 AM and [DATE] at 2:24 PM, with the DM (who toured with the survey team), revealed each kitchen staff member was responsible for cleaning the kitchen areas of which included the handwashing station, prep stations, surfaces, and floors between equipment, under the equipment and around the equipment in their work area every day after each meal. Continued interview revealed she recently, just this week, initiated a training module to educate herself and staff on the proper sanitation, storage, labeling and dates of stored food. Per the DM, there was an opening/closing daily cleaning schedule for all staff; however, she indicated the need to start a closer tracking system to monitor and audit the checklist to ensure staff were cleaning the cooking equipment after each meal service, checking to ensure food was being labeled, dated, rotated/discarded, and implementing proper food storage of the refrigerators and freezers. Per interview, she relied on all dietary staff to ensure the kitchen was clean, sanitary and a safe environment. During an interview on [DATE] at 3:40 PM, the Regional Dietician (RD) stated she expected the DM and kitchen staff to ensure they followed facility policies and procedures, along with the state and federal guidelines pertaining to the kitchen. She stated she expected the staff to serve, distribute and store the food in a sanitary manner to prevent cross contamination, as well as food allergies from the transfer of food particles on dirty surfaces. The RD stated food should be sealed completely when stored, labeled and dated, and discarded after the used by date and/or expired date. In addition, the RD stated she expected staff to clean equipment as they go to ensure the health and safety of all residents. During an interview on [DATE] at 4:30 PM with the Administrator, she stated she expected the kitchen staff to follow facility policies and procedures, as well as the federal and state regulations, pertaining to the kitchen area. In addition, she stated it would be her expectations for the Dietary Manager and kitchen staff to follow trainings for sanitation and labeling of food and adding staff should stay up to date on trainings. She stated her concern, if the training was not followed, would be the safety and well-being of the residents.

Based on observation, interview, review of facility policy, and review of manufacturer's information, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including open/use by/expiration dates and/or resident name for at least seven (Resident (R) 39, R26, R43, R5, R34, R25, and R48) of 43 residents whose medications were observed during an audit of three of the facility's four medication carts. The findings include: Review of the facility policy, Medication Administration Standard of Practice, with a review date of ,d+[DATE], revealed, When opening a multi-dose container, the date opened shall be recorded on the container. Expired/beyond use date medication should not be administered. Review of the facility policy, Label / Store Drugs & Biologicals Standard of Practice, last reviewed ,d+[DATE], revealed, Drugs and Biologicals must be labeled in accordance with currently accepted professional principles and include the expiration date when applicable. Further in the policy, the Protocol noted, Expired and / or discontinued medication shall be removed from the medication storage area for timely return to pharmacy and / or documented destruction .If a multi-dose vial has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for the particular vial. 1. Observation of the Top [NAME] medication cart on [DATE] at 8:02 AM revealed the following: a. R39 had one fluticasone propionate inhaler 250 mg / 50 mcg (milligram/microgram) which was dated with an open date of ,d+[DATE]. Storage instructions on the inhaler box read to Discard one month after opening the foil pouch or when the counter reads zero, whichever comes first. According to the manufacturer's instructions, the inhaler, which was still on the medication cart on [DATE], should have been discarded as it exceeded the recommended discard date of one month. b. One Wixela 500 / 50 inhaler, with 60 metered doses, did not have a label on the package or on the inhaler identifying the resident for whom it was prescribed. The box had the letters DS written in black ink; however, there was no open date documented. c. Levemir 100 units/milliliter (ml), 10 ml multidose vial for R26 showed a dispense date of [DATE]. The vial was opened, with no open date documented on either the vial or the box. d. R43 had a compounded medication - amantadine/meloxicam/topiramate/ Gaba / Lido ,d+[DATE]XXX[DATE]/5% topical cream in the cart. The label stated, Discard by [DATE]. 2. Observation of the Back East medication cart on [DATE] at 1:34 PM revealed the following: a. R5 had an albuterol sulfate 90 mcg / actuation inhaler which was opened with no open date found on either the box or the inhaler. b. R34 had fluticasone propionate 50 mcg two sprays daily for allergic rhinitis. The spray was dispensed [DATE] and was not labeled with an open date. c. R25 had Clearlax 17 grams by mouth daily as needed, which was dispensed [DATE]. The medication, which was opened, was not labeled with an open date. d. R48 had Clearlax 17 grams by mouth daily as needed, which was dispensed [DATE]. The medication, which was opened, was not labeled with an open date. In an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 8:31 AM, she stated the medications should have been dated and initialed when opened. Additional interview with LPN1 at 10:13 AM on [DATE] revealed the nurse who finds an expired medication should remove the medication from the cart, and the Director of Nursing (DON) office also completes audits of the medication cart as well. Interview with Kentucky Medication Aide (KMA) 1) and LPN1 on [DATE] at 1:55 PM confirmed that medications should be labeled by whoever opens the medication. At 2:01 PM on [DATE], LPN1 stated she thought the disposal date for inhalers was on the box for most of them and reiterated that medications should be dated and initialed when opened. Interview with LPN2 on [DATE] at 1:58 PM revealed inhalers should be disposed of 30 days after they are taken out of the foil and medications should be labeled by whoever opens the medication. Interview with the DON on [DATE] at 11:30 AM revealed medication cart audits were to be completed by the DON; however, she was not certain of the frequency this was to occur. She confirmed that her expectation was that medications past their 'beyond use' dates should be removed from the cart and the people working on the cart should address this. The DON stated it was important to label the medications and to remove the medications (when expired) as the effectiveness of the medication may be affected. Interview with the Administrator on [DATE] at 4:25 PM revealed it would be her expectation that medications were labeled and dated when opened and removed from the medication cart if expired to avoid a potential negative effect.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a Comprehensive Care Plan (CCP) was developed and/or implemented for four (4) of seventeen (17) sampled residents (Residents #8, #9, #10, and #13). 1. Resident #9 was known to wander excessively around the facility from [DATE] to February 2022. However, record review revealed the resident's care plan contained little to no interventions for protection of Resident #9 and/or other residents in the facility from his/her intrusive wandering behaviors. Resident #9 had thirty-nine (39) documented episodes of wandering behavior during the five (5) month timeframe which included: entering other residents' rooms; getting into other residents' personal belongings; lying on other residents' beds; and taking food off of others' trays. On [DATE] at 1:50 AM, Resident #9 was exhibiting wandering behaviors and sustained a fall which resulted in a Subdural Hematoma. Review of Resident #9's care plan revealed the facility failed to implement interventions to provide adequate supervision and protection for the resident. After the fall, the resident passed away on [DATE]. 2. Record review revealed the facility admitted Resident #8 on [DATE], with a history of falls, and assessed Resident #8 as severely cognitively impaired. Interview revealed on [DATE], Resident #8 experienced a change in behavior with increased agitation; staff notified the nurse. Resident #8's behavior change caused a Certified Nursing Assistant (CNA) to feel that she should sit outside the resident's room as a precaution. However, at break time the CNA, went off the unit leaving the resident unattended. Upon return from break, the CNA heard Resident #8's bed alarm sounding and found the resident lying on the floor beside his/her bed. The facility failed to ensure Resident #8's behavior care plan was implemented as the nurse failed to observe the resident for changes in his/her behavior after being notified by the CNA. Resident #8 was pronounced as deceased after the fall. 3. The facility admitted Resident #10 on [DATE], with diagnoses of unspecified Dementia with behavioral disturbance, and a history of repeated falls. The facility assessed Resident #10 as severely cognitively impaired, and care planned him/her for falls with interventions which included the resident's bed to be at the lowest level when staff were not providing care. However, on [DATE] the facility failed to implement the above intervention. Resident #10 fell from his/her bed which was raised to it's highest level. Resident #10 died after this fall. 4. The facility failed to develop and implement Resident #13's CCP to prevent falls and injuries by not ensuring the provision of his/her assistive devices. Resident #13 sustained thirteen (13) falls after his/her admission to the facility on [DATE], with eight (8) of the falls unwitnessed. Resident #13's last fall, on [DATE], resulted in the resident sustaining a large hematoma to the left side of his/her forehead. Interviews revealed Resident #13 did not have Dycem (a non-slip material used to prevent sliding) in his/her wheelchair at the time of the fall as required. Additionally, the facility noted the recommended intervention on the resident's falls events documentation; however, the facility failed to ensure those interventions were transferred to the resident's care plan. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care, F689 Free of Accident/ Hazards/ Supervision/ Devices at Scope and Severity of K; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plans at the Scope and Severity of K; 42 CFR 483.70 Administration, F835 Administration at the Scope and Severity of K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on [DATE]. An Extended and an IJ Removal Validation Survey was completed on [DATE], which determined the IJ had been removed on [DATE], as alleged. The remaining non-compliance continued in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plans at the S/S of a E; 42 CFR 483.25 Quality of Care, F689 Free of Accident/ Hazards/Supervision/ Devices at S/S of an E and 42 CFR 483.70 Administration, F835 Administration at the S/S of a E, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Comprehensive Care Plans dated ,d+[DATE], revealed the facility developed and maintained a Comprehensive Care Plan (CCP) for each resident to identify the highest level of functioning the resident might be expected to attain. Record review revealed the CCP was designed to identify problem areas for residents and incorporate risk factors. Continued review revealed the CCP was also designed to identify the professional services responsible for each element of a resident's care; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Further review revealed assessment of residents was to be ongoing and reflect the resident's condition changes. 1. Review of Resident #9's closed clinical records revealed the facility admitted him/her on [DATE], with diagnoses which included Dementia with Behavioral Disturbances. Review of the Admission Minimum Data Set (MDS) Assessment for Resident #9, dated [DATE], revealed the facility assessed the resident to have wandered one (1) to three (3) times per day during the assessment period. Per review of the MDS Assessment, the facility assessed Resident #9 as severely cognitively impaired as evidenced by the Brief Interview for Mental Status (BIMs) score of three (3) out of fifteen (15). Continued review of the MDS Assessment revealed the facility assessed Resident #9 as: having no upper or lower impairments; able to walk in his/her room without assistive devices; and as able to move about the unit. Further review revealed Resident #9 required: one (1) person physical assist for transfers; set-up only for bed mobility; and staff support for toileting. In addition, the facility assessed Resident #9 to need supervision and oversight when he/she completed Activities of Daily Living (ADLs) on his/her own. Review of Resident #9's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident to require a one (1) person physical assist for bed mobility (previously required only set-up); getting dressed; toileting; and for personal hygiene. Further review of the Quarterly MDS Assessment revealed the facility assessed Resident #9 to still require supervision for ADLs. Review of Resident #9's CCP, dated [DATE], revealed the facility developed a Fall Care Plan for the resident. Continued review revealed interventions, dated [DATE], which included: staff to aid him/her with ADLs daily as needed; administer medication per orders; explain care before giving it; bed against the wall; shoes or nonskid socks on when out of bed; remind to use call light and staff to answer it promptly; proper lighting; physical, occupational and speech therapy as needed; and toilet as needed or offer bedpan as needed. Continued review of the CCP revealed an intervention dated [DATE], and a therapy evaluation for ambulation intervention dated [DATE]. Review of Resident #9's CCP, revealed the facility noted on [DATE], the resident had behaviors of wandering, a cognitive decline and was picking up other residents' belongings. The CCP review revealed interventions, dated [DATE], that included: to allow the resident time to verbalize his/her feelings; encourage family visits; encourage the resident to join activities and invite him/her to programs; engage him/her in chore like activities such as folding clothes, sweeping and making beds; monitor for depression and schedule psychiatrist and Social Services visits as needed. Review of the Progress Notes for Resident #9 for the dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] at 11:08 PM, [DATE] at 12:36 AM, [DATE], [DATE], [DATE] at 3:40 AM, [DATE] at 12:13 AM, and ,d+[DATE] at 10:14 PM,[DATE] at 12:31 AM, [DATE], [DATE] at 10:30 PM, and [DATE], [DATE] at 8:40 PM, [DATE] at 9:47 PM, [DATE] at 4:49 AM, [DATE] at 8:39 PM, [DATE], [DATE] at 9:21 PM, [DATE] and [DATE], revealed the resident wandered throughout the facility, went in and out of other residents' rooms getting into their personal property, attempted to lie with other residents on their beds, took food off their meal trays. Review of the progress notes revealed Resident #9 had also became agitated and argumentative with staff's redirection. Review of the progress notes dated [DATE] at 10:31 PM, [DATE] at 8:51 PM, ,d+[DATE] at 9:01 PM, [DATE] at 3:07 PM, and [DATE] at 8:56 PM, revealed the resident continued displaying the same behaviors as he/she had from [DATE] through [DATE]; however, there was no documented evidence the facility attempted new interventions to address the behaviors. Continued review of Resident #9's Progress Notes revealed on: [DATE] staff notified the Psychiatrist with concerns regarding the resident's wandering behavior and increased agitation. Per review, on [DATE], Resident #9 was started on 0.5 milligrams (mg) of Ativan (an anti-anxiety medication). However, further review revealed no documented evidence other interventions were attempted by the facility to address the behaviors. On [DATE] at 8:48 PM, [DATE] at 11:49 PM, [DATE] at 11:48 PM, and [DATE] at 3:44 PM, the resident was noted as delusional and continued to wander in and out of other resident rooms with no documented evidence of new intervention to address the behaviors. Continued record review revealed on [DATE] at 10:03 PM, [DATE] at 8:44 PM and [DATE] at 3:17 AM, the resident continued to wander in and out of other residents' rooms, was delusional and intrusive throughout the night. Resident #9 became argumentative when redirected by staff with no documented evidence of new interventions attempted to address the behaviors. On [DATE] at 10:35 PM, [DATE] at 1:56 AM, and on [DATE] at 4:31 AM, the resident continued to wander throughout the facility, push other residents in their wheelchair, in and out of other resident rooms and went through their property. The resident was agitated when redirected with no documented evidence of new interventions attempted to address the behaviors. On [DATE] at 9:03 PM and on [DATE] at 11:15 AM, and [DATE] at 10:31 AM, the resident continued to wander in and out of other resident rooms, and became angry when redirected by staff, with no documented evidence the facility attempted new interventions to address the behaviors. On [DATE], the resident was out in the hall multiple times, could be redirected for short period of time then right back out into the hallway. However, there was no documented evidence of new interventions implemented to address the behavior. Continued record review revealed on [DATE] at 6:06 AM, and on [DATE], it was noted the resident was rude to staff when they redirected him/her after trying to enter other residents' rooms. Record review revealed on [DATE] at 10:27 PM; on [DATE] at 10:19 PM; on [DATE] at 9:11 PM, and [DATE] at 4:40 AM, the resident was noted to continue wandering in and out of other residents' rooms, being argumentative with staff when redirected and refusing to lay down. There was no documentation the facility attempted new interventions to address those behaviors. Record review revealed on [DATE] at 9:11 PM, the Director of Nursing (DON) noted the resident continued to wander in and out of other residents' rooms, attempted to help other residents transfer, and was irritable with redirection from staff, with no documented evidence of new interventions attempted to address the behaviors. Review of Resident #9's Progress Notes dated, [DATE] at 10:43 AM, revealed the Physician was notified of the resident's wandering in and out of other residents' rooms and his/her increased agitation. Per review, the Physician ordered the resident's Depakote (a mood stabilizing drug) to be increased to 1000 mg (milligrams). Further record review revealed, on [DATE] at 3:20 AM, the resident was noted to continue wandering in and out of other residents' rooms and as agitated when redirected by staff. However, record review revealed no documented evidence other interventions were attempted to address the behaviors. Review of Resident #9's Progress Notes revealed, on [DATE] at 1:50 AM, the resident was wandering the facility and went to the sunroom, and informed Door Greeter #2, he/she did not feel well. Continued review revealed the Door Greeter attempted to have Resident #9 sit down. Resident #9 again stated he/she did not feel well. Per review, the Door Greeter turned away from Resident #9 to go get staff, heard a thump. The Door Greeter turned around and observed the resident lying on the floor. Record review revealed nursing staff arrived to assess the resident, and found a large knot on the back on his/her head. The facility sent the resident out to the hospital emergency room (ER). Review further revealed Resident #9 returned to the facility on [DATE] at 7:30 AM with a diagnosis of Subdural Hematoma (a buildup of blood on the surface of the brain). Review of after care instructions for Resident #9, which the facility received revealed the resident was to be monitored for headaches, lethargy, change in cognition and behavior. The instructions stated if the resident had any changes in his/her condition the Physician was to be notified. However, continued record review revealed no documented evidence the facility addressed the hospital ER's aftercare instructions, nor implemented interventions for care of the resident following his/her diagnosis of Subdural Hematoma. Further review of Resident #9's closed medical record revealed the resident had continued having complaints of head pain on [DATE] and had redness observed around the crown of his/her head. Continued record review revealed on [DATE], Resident #9 was noted as lethargic and not opening his/her eyes to converse with others. Further record review revealed, on [DATE], Resident #9 complained of a headache to facility staff, stood up from a sitting position, fell face forward to the floor, and was pronounced as expired. Interview with Certified Nursing Assistant (CNA) #7, on [DATE] at 8:53 PM, revealed she witnessed Resident #9 wandering throughout the facility before his/her death. Per CNA #7, she had also seen Resident #9 wandering in and out of other residents' rooms and attempting to climb in other residents' beds. Further interview revealed she had never seen staff sitting with Resident #9, or have the resident do projects such as folding washcloths. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 3:30 PM, revealed she received the hospital ER's aftercare instructions on [DATE] when Resident #9 returned with the Subdural Hematoma diagnosis. She revealed she read through the instructions and looked for any changes in care or new orders; however, there were none. Continued interview revealed the instructions were just standard and are not really anything to do with the resident. LPN #1 stated if Resident #9 had required any additional monitoring it would have been documented in the daily log and then erased because they wrote that in pencil and erased it when the task was over. She further revealed it had been hard to determine when Resident #9 condition was outside his/her baseline as his/her baseline had already been bad. Interview with RN #2, on [DATE] at 7:23 PM, revealed she worked night shift and she was very familiar with Resident #9 and his/her wandering. Per interview, Resident #9 constantly wandered looking for his/her family. RN #2 stated she had the resident sit down with magazines which he/she liked to stack and sort. According to RN #2, Resident #9 never slept very much, and wandered in and out of other residents' rooms. RN #2 stated she had been concerned about Resident #9's safety when he/she wandered into other residents' rooms, as the resident took the other residents' personal property. Further interview revealed it was important for all staff to follow what the care plan interventions were because that was how the residents were kept safe and got the best care. Interview with RN #3, on [DATE] at 11:00 AM, revealed all staff members were to use residents' care plans when providing care because the care plans were developed to include the doctor's orders and care needs of the residents. Per RN #3, each resident's care plan was created specific to the resident and his/her care needs, and should be followed to ensure the residents received the best care possible. According to RN #3, Resident #9 wandered about the facility all the time, and had been easy to engage as he/she liked to sit down and talk. RN #3 revealed the other residents did not like it when Resident #9 entered their rooms. Continued interview revealed she had witnessed Resident #9 go in other residents' rooms and take their personal belongings. She stated she had also observed Resident #9 remove other residents' food from their meal trays. Per interview, Resident #9 had Dementia which had been worsening and staff had to keep up with the resident and redirect him/her. Further interview revealed Resident #9 had been much harder to redirect before he/she passed away. In addition, RN #3 stated all of the information regarding Resident #9's behaviors and actions should have been located on the resident's care plan. Interview with the MDS Coordinator/Floater on [DATE] at 3:08 PM, revealed she did not work solely for the facility as she was a floater (a contract employee) and had been since [DATE]. She stated she developed residents' CCPs when she completed their MDS Assessments. Per interview, she reviewed all new admissions after she was contacted by the Admissions Coordinator. Continued interview revealed she reviewed the MDS Assessments comparing them with the resident's care plan. She additionally stated the facility's IDT updated residents' care plans as changes in the residents occurred; however, she was not too involved with making care plan changes as the facility was the primary on that matter. The MDS Coordinator/Floater stated if she found any discrepancies with the MDS Assessments or residents' care plans she took the concerns to the DON to review and investigate. In addition, she stated she did not attend the facility's IDT meetings where residents' care plans were discussed and updated because she had not been asked to do so. Interview further revealed it could be a week or so between her visits to the facility. Interview with Resident #9's Primary Care Physician (PCP) on [DATE] at 12:30 PM, revealed the resident had advanced Dementia which prevented the resident to have the ability to follow any directions. Continued review revealed Resident #9's Dementia added to the resident's lack of safety awareness which made him/her a massive fall risk. The PCP stated he had not been notified of the resident having any symptoms after he/she returned to the facility on [DATE]. Per interview, if he had been notified of Resident #9 having redness around the crown of his/her head, and that he/she had a headache he would have had the resident transferred back to the ER for re-evaluation. Further interview revealed the facility should have implemented the ER's instructions upon Resident #9's return to the facility. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:30 PM, revealed she was responsible for supervision of the LPNs and RNs to ensure charting and interventions were completed. She revealed she double checked the intervention to make sure they were correct and were being followed. The ADON stated she reviewed discharge summaries for new admissions and readmissions and verified if there were any new orders. Continued interview revealed she and the DON reviewed all documents received when a resident returned from the ER. However, all staff were responsible for updating a resident's care plan to include new interventions, as needed. Per the ADON, all staff were to look at residents' care plans and ensure interventions were in place and appropriate for each resident. She stated management for each of the facility's departments was also responsible for ensuring residents' care plans were developed and changed as necessary. Further interview revealed residents' care plans were important as they noted everything residents' needed for their care and treatment, and they prevented bad things from happening with residents' care. The ADON stated if residents' care plans were not developed and followed as necessary a resident could be injured. Interview with the Director of Nursing (DON) on [DATE] at 3:45 PM, revealed all residents' care plans were developed and implemented, if needed, in the facility's daily Interdisciplinary/Clinical (IDT) meetings. She revealed Department Heads updated residents' care plan if necessary changes were within their subject matter. Continued interview revealed it was up to the facility's staff to look at residents' care plans and see what changes had been made each day, and administer the resident's care accordingly. The DON stated Resident #9 had wandered excessively; however, had been under a Physician and Psychiatrist's care. She revealed facility staff had placed a sign by Resident #9's door to cue him/her on were his/her room was. The DON further revealed the facility had never determined Resident #9 required any additional supervision nor, that he/she required any new interventions for his/her wandering and intrusive behaviors. Interview with the facility's Medical Director on [DATE] at 12:30 PM, revealed he did not provide care of residents who had an established Primary Care Physician (PCP). The Medical Director stated the only time he would involve himself in a resident's care who had not been assigned to him, was if their PCP was not providing appropriate care. Continued interview revealed the care plan was important for all residents and he expected staff would follow the care plans. According to the Medical Director, all Physician orders and instructions should be treated the same way and followed as required. The Medical Director stated he expected all the facility staff to follow its policies and procedures to ensure all residents received the highest level of care. Interview with the facility's Administrator on [DATE] at 12:54 PM, revealed residents' care plans were important because they were the outline for the care residents were to receive. The Administrator stated there was no one (1) person assigned to updating and developing residents' care plans because the facility took a team approach for that matter. She stated any staff person was able to update residents' care plans and staff did that. The Administrator stated she expected her staff to provide prudent nursing and CNA care. 44486 2. Review of the closed medical record for Resident #8 revealed the facility readmitted him/her on [DATE], with diagnoses that included Altered Mental Status, other Nondisplaced Fracture of second cervical vertebra and history of falls. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #8 as having a BIMS score of three (3), which indicated severe cognitive impairment. Review of the document,dated [DATE], titled Physicians Order Form As Of [DATE] for Resident #8 revealed the treatment orders included monitoring the resident every shift for side effects of his/her anti-anxiety, anti-depressant and anti-psychotic medications. Continued review of the Physician's Orders for Resident #8 revealed an order dated [DATE], from the resident's Primary Care Physician (PCP) for Resident #8 to be monitored for pain every using the Shift Pain Assessment Score of one (1) through (10). Further review of the orders revealed an order dated [DATE], for Resident #8 to have a sensor pad alarm on his/her bed when in bed to alert staff of unsafe transfer attempts related to his/her decreased safety awareness every shift. Review of Resident #8's Comprehensive Care Plan (CCP) revealed the facility had care planned the resident for his/her psychotropic drug use on [DATE]. Review of the CCP revealed the interventions included: observing the resident for adverse side effects of his/her anti-anxiety, anti-depressant, and anti-psychotic medications and document any side effects. Continued review of Resident #8's CCP revealed the resident was to have a pain assessment as ordered (every shift) and as needed (PRN) to be documented on the Medication Administration Record/Treatment Administration Record (MAR/TAR). Review of the CCP revealed on [DATE], the facility established a care plan related to Resident #8's behaviors with interventions which included observing the resident for changes in his/her behaviors. Further review of the CCP revealed the facility care planned Resident #8 for falls on [DATE], and noted the intervention dated [DATE] for the resident to have a sensor pad alarm to his/her chair and bed. Phone interview with Certified Nurse Aide (CNA) #11, on [DATE] at 2:40 PM, revealed when she worked on [DATE], she had not been assigned to Resident #8's care. CNA #11 stated on [DATE] at about 2:30 AM, she heard Resident #8 yelling for help and went to the resident's room to check on him/her. The CNA stated Resident #8's bed had been low to the floor; however, the resident looked as if he/she was going to fall out of the bed. She stated she stuffed a pillow against him/her to kind of secure the resident. Continued interview revealed the nurse, LPN #4 (Licensed Practical Nurse) had been sitting at the nurses' station with the door closed and earbuds in his ear and therefore had not heard Resident #8 yelling for help even though the resident had been yelling loud. CNA #11 stated after placing the pillow against Resident #8, she stopped at the nurse's station to tell LPN #4 about the resident. Further interview revealed LPN #4 told her he didn't hear anything, and CNA #11 told him that was because he had ear buds in his ears. CNA #11 further stated she returned to her assignments, and did not know if LPN #4 ever got up to check on Resident #8. Phone interview with CNA #12 on [DATE] at 10:00 PM revealed when she arrived to work, on the evening of [DATE], Resident #8 had been very agitated, much more so than normal. CNA #12 stated due to Resident #8's agitation, she had not been comfortable leaving him/her, and had sat at the resident's door. Continued interview revealed early the next morning ([DATE]) CNA #12 returned from her break and heard Resident #8's bed alarm going off and found the resident lying on the floor with his/her head in the trash can beside the bed. CNA #12 stated LPN #4 had not responded to Resident #8's bed alarm going off, so she went to the nurses' station to get assistance. Per CNA #12, she had to place her hand on LPN #4's shoulder to get his attention. Further interview revealed when LPN #4 arrived at Resident #8's room at approximately 5:00 AM (on [DATE]), he observed Resident #8 lying on his/her floor mattress face down. CNA #12 further stated LPN #4 assessed Resident #8 to have no pulse or respirations. Resident #8 was pronounced expired. Review of the facility's document titled, Provider Assignment Record, dated [DATE], revealed LPN #4 had been assigned to the care of residents in the entire building. Further review revealed LPN #4 had arrived at 6:50 PM and departed at 6:30 AM on [DATE]. Phone interview on [DATE] at 6:00 PM, with LPN #4 revealed he had no knowledge of Resident #8 behaviors that night, until he was called to the resident's room and he had no idea what had happened to him/her. Per interview, LPN #4 stated he did not recall CNA #11 talking to him about Resident #8 yelling out at 2:00 AM (on [DATE]). LPN #4 further stated he had rounded at 4:00 AM with the aides and Resident #8 had been fine at that time. Review of the facility's document, dated [DATE] 6:50:30 PM titled, General Form (2) revealed on [DATE] at approximately 5:00 AM, CNA #12 came to LPN #4 and told him Resident #8 was lying on his/her floor mat beside the bed and was unresponsive. Continued review revealed LPN #4 assessed Resident #8 and the resident had no pulse or respirations, and was noted as expired. Review of Resident #8's MAR/TAR documentation for [DATE], for LPN #4's shift beginning at 6:00 PM on [DATE] and ending at 6:00 AM on [DATE], revealed no documented evidence LPN #4 had implemented the resident's care plan interventions for monitoring him/her every shift for side effects of antianxiety, antidepressant or antipsychotic medications. Continued review also revealed no documented evidence LPN #4 had verified the placement of Resident #8's bed sensor alarm as per the resident's care plan interventions. Interview with Registered Nurse (RN) #3 on [DATE] at 11:00 AM revealed it was important for all staff to follow residents' care plans because the care plan included the doctors' orders. RN #3 stated residents' care plans were individualized based on the resident's needs. Interview with the DON on [DATE] at 6:07 PM revealed nurses documented completed treatments on the residents' MAR/TAR. Per the DON, nurses initialed in the appropriate box on the MAR/TAR after completion of treatments which indicated the treatment had been provided as ordered. Continued interview revealed from 6:00 PM on [DATE] until 6:00 AM on [DATE], LPN #4 had been responsible for ensuring Resident #8's care plan treatment interventions were completed including: checking the resident's bed alarm for his/her safety; monitoring the resident's behaviors; and assessing Resident #8's pain level. The DON revealed if a resident's treatment box was not initialed and was left blank there was no evidence the treatment was completed. Further interview revealed she was aware LPN #4 had not initialed Resident #8's MAR/TAR as completed for the monitoring of his/her antipsychotic medications, and monitoring for the resident's pain level treatments even though assigned to do so. 3. Review of Resident #10's closed clinical record revealed the facility admitted Resident #10 on [DATE] with diagnoses that included unspecified Dementia with behavioral disturbance, Tremor, and repeated falls. Review of the Quarterly MDS Assessments dated [DATE], revealed the facility assessed Resident #10 as not interviewable with a BIMS score of three (3) which indicated the resident was severely cognitively impaired. Review of the facility's Fall Risk Assessment, dated [DATE], for Resident #10 revealed the facility assessed the resident to have a score of eleven (11), indicating the resident was at high risk for falls. Review of Resident #10's Physician's Order, dated [DATE] at 12:00 AM, revealed an order for the resident to have a low bed when in bed to reduce injury related to decreased safety awareness every shift. Review of Resident #10's CCP revealed the facility care planned the resident for at risk for falls on [DATE], with interventions which included the resident's bed being at the lowest level when staff were not providing car [TRUNCATED]

Based on interview, record review, review of the facility's Administrator Job Description, and review of the facility's policy, it was determined the facility failed to be administered in a manner to use its resources effectively and efficiently to ensure residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being for four (4) of seventeen (17) sampled residents (Residents #8, #9, #10, and #13). Refer to F656 and F689. The facility's failure to have an effective system in place to ensure the facility was administered effectively caused or was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/30/2022, and was determined to exist on 10/31/2021. The facility was notified of the IJ on 06/30/2022. The facility provided an Acceptable IJ Removal Plan on 07/06/2022, which alleged the removal of the IJ on 07/06/2022. The State Survey Agency (SSA) determined substantial compliance was achieved on 07/06/2022, as alleged. Immediate Jeopardy was identified, on 06/30/2022, and was determined to exist on 10/31/2021 in the areas of 42 CFR 483.25 Quality of Care, F689 Free of Accident/ Hazards/Supervision/Devices at Scope and Severity of K and 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plans at a Scope and Severity of K; 42 CFR 483.70 Administration, F835 Administration at a Scope and Severity of K. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident/Hazards/Supervision/Devices at a Scope and Severity of K. The facility was notified of the Immediate Jeopardy on 06/30/2022. An Extended and an IJ Removal Validation Survey was completed on 07/13/2022, which determined the IJ had been removed on 07/06/2022, as alleged. The remaining non-compliance continued in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plans at the S/S of a E; 42 CFR 483.25 Quality of Care, F689 Free of Accident/ Hazards/Supervision/ Devices at S/S of an E and 42 CFR 483.70 Administration, F835 Administration at the S/S of a E, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's Administrator Job Description, undated, revealed the Administrator directed the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that governed nursing facilities to assure the highest degree of quality of care was provided to the residents at all times. Per review of the Job Description, the Administrator's duties and responsibilities encompassed facility and compliance management, staffing and retention, business management, marketing and revenue management and community relations. Continued review revealed the Administrator was to ensure excellent care for residents was provided by overseeing and monitoring the care services being delivered. Further review revealed the Administrator worked with the supervisors providing instruction, guidance, and counseling as necessary to ensure complete understanding of their responsibilities. The Administrator coordinated with the Regional Director and Human Services for employee termination as necessary. Additionally, the Administrator directed the facility's Committees and meetings per its policies and ensured maintenance of accurate medical records for billing, auditing and regulatory compliance within appropriate guidelines and performed other additional duties as assigned. Review of the facility's policy titled, Comprehensive Care Plans, dated 10/2020, revealed the facility developed and maintained a Comprehensive Care Plan (CCP) for each resident to identify the highest level of functioning the resident might be expected to attain. Per the policy, the CCP was designed to identify problem areas and incorporate risk factors for residents. Continued review revealed the CCP also identified the professional services responsible for each element of care for residents; and aid in preventing or reducing declines in the residents' functional status and/or functional levels. Record review revealed the assessment of the resident was ongoing and would reflect the resident's condition change. Review of the facility's policy titled, Falls Standards of Practice, dated 07/2020, revealed each resident would receive adequate supervision to prevent accidents. Review of the facility's Incidents/Accidents Standard of Practice policy, dated 02/2021, revealed its purpose was to ensure the facility's environment was as free from accident hazards over which the facility had control. Continued review revealed additional purposes of the policy included ensuring each resident received adequate supervision and assistive devices to prevent avoidable accidents. Further review revealed the facility's Interdisciplinary Team (IDT) was to review risks, ensure appropriate interventions, and identify trends for those residents with falls and other accident-related injuries. Review of the facility's policy titled, Safety/Supervision, dated 02/2021, revealed resident safety and supervision was a facility-wide priority. Per review, staff were to use various sources to identify risk factors for residents, through information obtained by medical history, physical exam and observations. Further review revealed interventions to reduce risks and hazards might include communicating specific interventions to all relevant staff, documentation of interventions, modification of interventions and assessment of interventions for effectiveness and changes as necessary. Interview with the Administrator on 06/08/2022 at 12:54 PM, revealed the facility had morning clinical meetings which were also called the facility's IDT meetings. She stated a meeting was held each day related to a certain subject that was to be covered each week. Continued interview revealed any concerns from the prior night were discussed even if the concern was not related to that day's care area. The Administrator stated she directed and guided the nursing staff to ensure they did what they were supposed to do. She stated during the IDT/Clinical Meetings staff discussed any changes related to a resident and she directly confirmed the information was updated in the computer. Interview revealed Residents #8's, #9's and #10's deaths had all been investigated, with only one (1) of the deaths being required to be reported to the State Survey Agency (SSA). She stated when a resident's death occurred in the facility, staff contacted the Director of Nursing (DON) and the Medical Director, with the DON contacting the Administrator. According to the Administrator, Resident #10's death had triggered an investigation and report to the SSA because the fall was witnessed by the resident's roommate and his/her bed being in a position which had been high up. The Administrator stated there was nothing clearly defining what happened to the resident. Interview, on 06/08/2022 at 12:54 PM, with the Administrator revealed Resident #8's family had never spoken to her regarding any concerns in reference to the resident's death. She stated Resident #8 had not had any bruises on his/her body and nothing was reported to her regarding bruising. Per the Administrator, there had been nothing about Resident #8's death that led her to believe his/her fall was the cause of his/her death and, there was no way to determine what happened other than just death. Continued interview revealed the Assistant Director of Nursing (ADON) and the DON were responsible for ensuring staff were educated on monitoring residents at night and ensuring appropriate documentation including the monitoring. She stated the ADON, and DON were also responsible for audits and for bringing any concerns they had to the facility's Quality Assurance (QA) Meetings. The Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) Committee included all department heads within the facility. She stated the facility had previously identified there was a high number of falls and a plan had been developed for the identified concern. Interview revealed the plan developed was to monitor and review residents' interventions and ensure appropriate interventions were in place. The Administrator stated no patterns had been identified for any specific resident. She stated the facility's resident fall numbers decreased in May 2022, and were below the national average. Interview revealed, the Administrator had been unable to provide any documentation to account for the plan, audits and/or outcome for the SSA Surveyor's review. Further interview with the Administrator on 06/08/2022 at 12:54 PM, revealed she did not have any concerns with staffs use of earbuds or phones within the facility. She revealed if it did not take place in the resident care areas it was not a concern. She stated it was her expectation that staff would let other staff know when they went on the breaks or lunch. Continued interview revealed this was important to ensure the resident's care was covered. She stated staff were expected to check on residents every two (2) hours and that information was to be documented in the medical record. The Administrator stated, she expected her staff to provide prudent nursing and Certified Nursing Assistant (CNA) care. Interview with the Administrator, on 06/08/2022 at 12:54 PM, revealed the responsibility of the residents' safety' and wellbeing fell on her and the governing body. Additional interview with the Administrator on 06/28/2022 at 1:26 PM, revealed the facility had conducted ongoing audits of documentation of nurses and CNAs to ensure no holes were present and the Medicine Administration Record (MAR) and Treatment Authorization Request (TAR) were complete. She was unable to provide dates or documentation of said audits. The facility took the following actions: 1. On 07/01/2022 the Director of Nursing (DON) reviewed Resident #13's care plan to ensure all fall interventions were current for the resident and verified each intervention was in place and implemented. 2. Each resident was assessed by a licensed nurse which included but not limited to skin, pain, vital signs, oxygen saturation, orientation/level of consciousness/mood, and respiratory and breath sounds. These were completed by 07/05/2022. After completion of the assessments, the assessments were reviewed by the Assistant Director of Nursing (ADON) and the DON. No concerns were found to be addressed. 3. The ADON and DON reviewed all Progress and Nursing Notes for the prior thirty (30) days to review if staff documented changes in residents' conditions and ensure the changes had been placed on the care plan with no updates required. This was completed on 07/01/2022. 4. The ADON and DON reviewed all fall incidents for the prior thirty (30) days to ensure the care plan had been updated to include applicable interventions and interventions were being implemented as specified. This was completed on 07/05/2022. 5. The ADON and DON reviewed Behavior and Fall care plans for each applicable resident (residents who had current Fall and Behavior care plans), to ensure interventions were current and implemented. This was completed on 07/05/2022. 6. On 07/01/2022, the [NAME] President of Operations (VPO) provided education to the Administrator in reference to F835 regarding care management and resource utilization. Discussion included management of the facility must be in a manner in which resources were used to achieve and maintain the highest practicable physical, mental and psychosocial well-being of each resident. The resources to be used included, but were not limited to the facility's operating budget, staff, supplies, and/or other services necessary to provide for the needs to the residents. 7. An AdHoc QA meeting was held, on 06/30/2022, to review the Immediate Jeopardy notifications and an immediate action of a removal plan was put together. This included audits, education and monitoring. The Administrator, DON, ADON, Regional Quality Manager (RQM), [NAME] President of Operations (VPO), Clinical Manager (CM) and Medical Director present via phone. 8. Beginning 07/05/2022 the VPO, and/or the RQM and/or the Clinical Risk Manager (CRM) would be onsite for a minimum of weekly to review and validate the status of the IJ removal action plan with the Administrator, while the facility remained in IJ status. They were to review audits, education, and monitoring of F656 and F689. 9. A second AdHoc QA meeting was held on 07/05/2022 to review the IJ action plan and to prepare the monitoring plan. The meeting was attended by the Administrator, DON, ADON, RQM, VPO, CM and the MD (via phone). The State Survey Agency (SSA) validated the facility took the following actions: 1. Interview with the ADON, on 07/13/2022 at 5:30 PM and the DON at 5:40 PM, revealed they reviewed Resident #13's care plan and ensured all necessary fall interventions were present on the care plan. The SSA Surveyor reviewed Resident #13's care plan and verified all needed interventions were added. Review of the Progress Note, dated 07/01/2022, revealed the DON documented the IDT met and discussed Resident #13's plan of care. Continued review revealed the resident had anitroll device on back of the wheelchair, dycem in the wheelchair, a clip alarm to the wheelchair, and the bed was in the lowest position and a mattress on the floor. The DON documented the Care Plan was reviewed and updated as appropriate. The ADON and DON signed off on the care plan audit sheets. 2. Interview with RN #2 and RN #3, and LPN #1, LPN #7 and LPN #2 on 07/13/2022 at 3:40 PM, revealed they assisted with completing assessments of all residents which included: assessing the residents' oxygen saturation, skin, pain level, vital signs, respiratory and breath sounds, and their level of consciousness/orientation. Interview with the ADON and DON on 07/13/2022 at 5:30 PM, revealed they had reviewed all completed resident assessments with no new concerns identified. Per interview, they validated all residents were assessed as per the IJ removal plan. Review of the residents' assessments revealed they were completed by the nursing staff and verified completion, as alleged. No concerns were identified. 3. Interview with the ADON and DON on 07/13/2022 at 5:30 PM revealed they reviewed the last thirty (30) days of residents' Progress Notes for any concerns related to change in the resident's condition and ensured the care plan was revised if needed. Per the DON and ADON, they had not identified any concerns. Further interview revealed they completed their review on 07/01/2022. The SSA Surveyor reviewed the last thirty (30) days of residents' Progress Notes reviewed by the DON and ADON, with no concerns identified. Further review revaled the ADON, and DON reviewed the notes, highlighted the resident name once completed and signed their name on the bottom of the name list. 4. Interview with the ADON and DON, on 07/13/2022 at 5:30 PM, revealed they reviewed the past thirty (30) days of residents' fall incidents to ensure the residents' care plans were updated with the interventions and that the interventions were implemented as required. The SSA Surveyor reviewed fall incidents for the last thirty (30) days and found no concerns. The facility identified a root cause A for each resident's fall and put a new intervention in place, if required. The ADON and the DON signed the document when they completed the task. 5. Interview with the ADON and DON on 07/13/2022 at 5:30 PM, revealed they reviewed care plans for residents identified as fall and behavior concerns to make sure the interventions were in place and implemented. The SSA Surveyor reviewed the care plans and looked at residents who were identified with behavior or falls concerns, with no concerns identified. A root cause was identified for each fall and a new intervention was put in place if required. Behaviors were reviewed in the same manner. The ADON and the DON signed the document when they completed the task. They also reviewed each fall care plan. 6. Interview with the VPO, on 07/13/2022 at 4:10 PM, revealed she educated the Administrator about the requirements of F835, reviewed the requirements of the regulation and much of the information was reinforcement of information the Administrator already knew. Per interview, no post-test was given; however, she had utilized verbal discussion of the regulations with the Administrator. The VPO was there for support to the Administrator throughout the IJ process and she attended the facility's Quality Assurance (QA) meetings. Interview with the Administrator on 07/13/2022 at 5:45 PM, revealed he had been provided the education on F835 by the VPO. 7. Interview with the Administrator, the DON and the ADON, on 07/13/2022 at 5:45 PM, revealed an AdHoc QA meeting had been held on 06/30/2022, when the Immediate Jeopardy was called. Continued interview revealed they along with all the facility's department heads, the RQM, VPO, CRM and the Medical director (who had been present via phone) were present for the AdHoc QA meeting. Further interview revealed they started to plan for the IJ removal and for the audits, monitoring and education that would take place during that meeting. The SSA Surveyor reviewed the AdHoc QA meeting sign-in sheet for the 06/20/2022 meeting, and verified the Administrator, DON, ADON, RQM, signed in as present in person and the VPO, CRM and Medical Director signed in as present via telephone for the meeting. The SSA Surveyor completed review of the facility's audits and sign in sheets, with no concerns noted. Interview with the Medical Director on 07/13/2022 at 3:53 PM, revealed he had been present via telephone for the facility's AdHoc QA meeting, in which there was IJ removal discussions. He stated he reviewed the facility's audits and education that had been provided. Per the Medical Director, the facility's IDT team looked at resident falls, reviewed medications changes, and decreased medication as needed for individual care. He stated the facility's audits were ongoing twice a week as far as he could recall. Further interview revealed the facility's audits were important to have to ensure the facility made progress. Interview with the CRM, on 07/13/2022 at 3:30 PM, revealed she had authorized the Immediate Jeopardy (IJ) Removal Plan, and worked to assist the facility with anything they needed to execute the IJ removal plan. According to the CRM, she was a resource provider for the facility, and had put the IJ removal plan together in an operational way. She stated the facility's IDT had also contributed to the IJ removal plan, and the RRM put the plan into a form that had been acceptable. She further revealed for the facility's 06/30/2022 AdHoc QA meeting regarding the IJ, she had been present via the telephone. Interview with the VPO, on 07/13/2022 at 4:10 PM, revealed her role in the IJ removal had been to offer support for the facility. She stated she attended the facility's Quality Assurance (QA) meetings. 8. Observation on 07/12/2022 and 07/13/2022 revealed the RQM present at the facility. Review of the facility's a sign in sheet documentation revealed on 07/05/2022 the VPO, RQM and the CRM were present at the facility. Continued review of the sign in sheet documentation revealed the RQM and the CRM had been present at the facility on 07/06/2022 and 07/07/2022, and the VPO present on 07/11/2022. Interview with the VPO, RQM and CRM on 07/13/2022 at 4:10 PM, revealed one of them were present in the facility at all times during the required timeframe to help review the status of the IJ until the removal plan was accepted. 9. Interview with the DON, on 07/13/2022 at 5:30 PM, revealed each required staff member had been present for the 07/05/2022 AdHoc meeting in which the plan to monitor the necessary areas was established. Interview with the RQM on 07/13/2022 at 3:40 PM, confirmed the Administrator, DON, ADON, RVP, CRM and Medical Director via phone were all present for the second AdHoc QA meeting on 07/05/2022. Review of the 07/05/2022 AdHoc QA sign in sheet revealed the Administrator, DON, ADON, RQM, VPO, CRM and Medical Director (via phone) had all been present for the meeting.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure four (4) of seventeen (17) sampled residents (Residents #8, #9, #10 and #13) received the necessary care and services to prevent accidents resulting in injury. 1. Resident #9 sustained a fall on [DATE] at 1:50 AM, and had complaints of head and neck pain, and was transported to the hospital Emergency Department (ED) where he/she was diagnosed with a subdural hematoma. Resident #9 was readmitted to the facility on [DATE] at 7:30 AM with continued complaints of head pain. However, record review revealed no documentation related to discharge instructions for care of Resident #9's subdural hematoma, and no documented evidence the facility implemented interventions regarding follow-up care of the resident, such as increased supervision or monitoring of him/her. Resident #9 continued to have complaints of head pain on [DATE] and was observed to have redness around the crown of his/her head. Resident #9 was noted as lethargic on [DATE], and did not open his/her eyes to converse with others. On [DATE], Resident #9 complained of a headache to facility staff, stood up from a sitting position, and fell face forward to the floor. Resident #9 was pronounced as expired. In interview, Resident #9's Physician revealed the resident had been unable to follow directions, had no safety awareness, and was a massive falls risk. 2. The facility assessed Resident #10 as severely cognitive impaired and to have a diagnosis of Dementia. Resident #10 sustained four (4) falls between [DATE] and [DATE]. Review of the resident's care plan revealed the facility had implemented an intervention on [DATE] for Resident #10's bed to be at lowest level when staff were not providing care for him/her. Per record review, the facility failed to identify risk factors for Resident #10 related to the falls he/she experienced in [DATE] and February 2021, and failed to identify the resident's need for increased supervision. On [DATE], Resident #10 sustained a fall from his/her bed, which was in the highest position. Resident #10 was pronounced dead. 3. The facility assessed Resident #8 as severely cognitively impaired and at high risk for falls. Resident #8 sustained seven (7) falls between [DATE] and [DATE]. CNA #12 revealed she had concerns about the resident; however, failed to report her concerns regarding Resident #8 to the nurse on duty. CNA #12 had concerns about Resident #8 being more agitated than normal the evening of [DATE], and had not felt comfortable leaving the resident alone, and had sat outside his/her room door. However, when CNA #12 left for her break at 4:30 AM on [DATE] she failed to have other staff watch over her assigned residents, which included Resident #8. Upon return from her break, CNA #12 heard Resident #8's bed alarm going off and found the resident lying on the floor with his/her head in the trashcan. CNA #12 notified Licensed Practical Nurse (LPN) #4 who arrived at Resident #8's room at 5:00 AM on [DATE]. LPN #4 assessed Resident #8 to have no pulse or respirations, and the resident was pronounced dead. 4. The facility admitted Resident #13 on [DATE] with a history of falls, and assessed the resident as severely cognitively impaired. Resident #13 sustained twelve (12) falls from [DATE] through [DATE], with eight (8) of the falls unwitnessed. The facility implemented care plan interventions for Dycem (a non-skid padding) in Resident #13's wheelchair seat, and a clip alarm in place when the resident was up in his/her wheelchair. However, staff revealed on [DATE], when Resident #13 experienced the fall, he/she did not have the Dycem in the seat of his/her wheelchair and did not have the clip alarm in place as per his/her care plan. The facility's Interdisciplinary Team (IDT) failed to identify the root cause of the falls Resident #13 sustained from [DATE] through [DATE], and failed to implement interventions necessary for the resident's safety. Resident #13 had a fall on [DATE] and sustained a large hematoma to the left side of his/her head. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plans at the Scope and Severity (S/S) of a J; 42 CFR 483.25 Quality of Care, F869 Free of Accident/ Hazards/Supervision/ Devices at Scope and Severity of a K; and 42 CFR 483.70 Administration, F835 Administration at the Scope and Severity of a K. Additionally, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689 Free of Accident/Hazards/Supervision/Devices at Scope and Severity of K. The facility was notified of the Immediate Jeopardy on [DATE]. An Extended and an IJ Removal Validation Survey was completed on [DATE], which determined the IJ had been removed on [DATE], as alleged. The remaining non-compliance continued in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656 Develop/Implement Comprehensive Care Plans at th S/S of a E; 42 CFR 483.25 Quality of Care, F689 Free of Accident/ Hazards/Supervision/ Devices at S/S of an E and 42 CFR 483.70 Administration, F835 Administration at the S/S of a E, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's, Incidents/Accidents Standard of Practice policy dated ,d+[DATE], revealed its purpose was to ensure that each of the facility's residents received adequate supervision and assistive devices to prevent avoidable accidents. Further review revealed for residents with falls and other accident-related injuries the facility's Interdisciplinary Team (IDT) was to review the risks, appropriate interventions, and trends for those residents. Review of the facility's policy, Safety/Supervision, dated ,d+[DATE], revealed resident safety and supervision were a facility-wide priority. Continued review revealed facility staff were to use various sources to identify the risk factors for residents. Per review, staff were to identify the residents' risk factors through information obtained from the medical history, physical exam and observations of the residents. Further review revealed interventions to reduce the risks and hazards for residents were to be communicated to all relevant staff and documented. In addition, residents' interventions were to be assessed for their effectiveness and changes made as necessary. Review of the facility's policy, Falls Standards of Practice, dated ,d+[DATE], revealed each resident was to receive adequate supervision to prevent accidents. 1. Review of Resident #9's clinical record revealed the facility admitted the resident on [DATE], with diagnoses which included Dementia with behavioral disturbances, Spondylolysis and Lumbago with Sciatica. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #9, dated [DATE], revealed the facility assessed him/her with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated the resident was severely cognitively impaired. Continued review of the MDS Assessment revealed the facility assessed Resident #9 to have no behaviors present. Per review of the MDS, the facility assessed Resident #9 to require physical assistance of one (1) staff for bed mobility and toileting. Further review revealed the facility also assessed Resident #9 to require limited assistance by staff for his/her mobility, and to require supervision for transfers, walking in the corridor and for eating. Review of the facility's fall assessment documentation for the time period of [DATE] through [DATE] revealed the facility assessed Resident #9 with a score of two (2), which indicated he/she was a low risk for falls (a score of ten (10) or higher was noted as a higher fall risk). Review of Resident #9's Comprehensive Care Plan (CCP), dated [DATE], revealed the facility care planned the resident for being at risk for falls related to decreased safety awareness, weakness and Dementia. Continued review revealed the interventions included: to explain treatments; ensure the resident's bed was against the wall; and ensure proper shoes or nonskid socks were in place and the pathway was clear. Further review revealed interventions that included: orient the resident to the call light and answer it promptly; assist him/her with Activities of Daily Living (ADLs); provide proper lighting; and help with toileting. In addition, review further revealed an intervention added on [DATE], to have Resident #9 assessed for ambulation (which never occurred as the resident expired before therapy assessed him/her). Additional review of Resident #9's CCP revealed the facility care planned the resident's wandering behaviors, cognitive decline and picking up others' belongings. CCP review revealed the interventions dated [DATE] included staff to engage Resident #9 in activities of interest such as household chores, folding wash clothes, sweeping and making beds. Review of Resident #9's Progress Notes from ,d+[DATE] to ,d+[DATE] revealed the resident had experienced thirty-nine (39) episodes of excessive wandering throughout the facility and in and out of other residents' rooms. Continued review of the Progress Notes for that time period revealed Resident #9 was also documented to have gotten into other residents' belongings, taking food off the other residents' trays and attempting to get into other residents' beds. Review of the Progress Notes, dated [DATE] and [DATE], revealed the Psychiatrist increased Resident #9's Risperdal (an antipsychotic medication) dosage on those dates due to his/her continued behavior disturbances. Review of the Progress Note for Resident #9, dated [DATE] at 2:26 AM, completed by the Director of Nursing (DON) revealed at 1:50 AM, the resident had been wandering the facility per his/her usual, and had gone to the front porch where the facility's door greeter observed him/her stumble and fall backwards to the floor. Continued review, of the [DATE] Progress Note, revealed upon assessment Resident #9 was noted as awake, alert to self, and pleasantly confused per his/her usual. Review of the [DATE] Progress Note, revealed Resident #9 complained of neck and head pain, and there had been a large knot observed to the back of his/her head. Further review of the Progress Note revealed Emergency Medical Services (EMS) was called and a Certified Nurse Aide (CNA) stayed with Resident #9 to keep his/her head still until EMS arrived. Review of the [DATE] Progress Note revealed Resident #9 was transported to the hospital Emergency Department (ED) for evaluation of his/her complaints of head and neck pain. Review of Resident #9's Progress Notes revealed a note, dated [DATE] at 7:30 AM, that stated the resident return to the facility; however, there was no care of the resident's diagnosed subdural hematoma noted, nor interventions documented for follow-up care of him/her, such as increased supervision or monitoring for complications. Review of a Progress Note, dated [DATE] at 2:31 AM, revealed Resident #9 continued to complain of head pain and staff had observed redness around the crown of the resident's head. Review of the Progress Note, dated [DATE] at 9:52 PM, revealed the resident had been lethargic and not opening his/her eyes. Review of the Progress Note, dated [DATE] at 1:39 AM, revealed staff heard a resident yell for help and upon arrival to Resident #9's room they found the resident on the floor. The roommate reported the resident had been seated at the side of the bed, said his/her head hurt, stood up and fell face forward. The resident did not put his/her hands out to protect himself/herself. Registered Nurse (RN) #2, assessed the resident and found him/her to be without pulse or respirations. Emergency Medical Services were called and once they arrived they determined the resident was without signs of life. Review of the facility's fall event information dated, [DATE] at 8:50 PM, revealed Resident #9 had been found by staff lying prone on the floor near his/her bed. Per review, staff had heard Resident #9's roommate calling for help and responded by going to the room, where they found Resident #9 unresponsive, with no pulse or respirations. Continued review revealed Resident #9's roommate told staff the resident had complained about a headache, and then stood up, falling forward. Review of the Telepsychiatry Evaluation for Resident #9, dated [DATE], revealed the resident had experienced escalated behaviors and intrusiveness which was a safety concern for the resident, as well as for other facility residents. Continued review revealed the Psychiatrist recommended Resident #9's Depakote (a mood stabilizing medication) dosage be increased, noted the resident needed to be monitored for worsened akathisia (inability to remain still) and falls. Interview on [DATE] at 9:45 PM, with Certified Nursing Assistant (CNA) #16 revealed on [DATE], she faintly heard someone calling her name, and responded finding it was Resident #9's roommate calling out for help. She stated when she arrived in Resident #9's room, the resident was lying on the floor, face down with his/her hands at the side. Continued interview revealed she placed her hand on Resident #9's back to feel for respirations and called the resident's name out several times; however, the resident did not respond. CNA #16 further stated Registered Nurse (RN) #2 came to Resident #9's room and assessed the resident and decided to call 911. Further interview revealed CNA #16 stated Resident #9 had an order for Do Not Resuscitate (DNR). Interview, on [DATE] at 7:23 PM, with RN #2, revealed she could not recall the events of the night of [DATE], even though she was the Charge Nurse that evening. Interview, on [DATE] at 11:00 AM, with RN #3 revealed Resident #9 displayed wandering behaviors, and it had been up to staff to keep up with him/her and provide redirection as necessary. Further interview revealed redirecting Resident #9 had became much harder related to his/her advanced Dementia. Interview on [DATE] at 10:50 AM, with the facility's contracted Psychiatrist revealed her role for the facility was as a consultant. Per interview, she made recommendations regarding residents' care needs, and the Primary Care Physician (PCP) decided whether to adopt her recommendations. Continued interview revealed the facility had discussed with her Resident #9 being moved to a locked unit for increased supervision; however, she did not know why the resident was never moved. Further interview revealed it was her understanding, once she got Resident #9's wandering and impulsivity under control with the use of medication, the resident was to be moved. Interview on [DATE] at 3:45 PM, with the Director of Nursing revealed the facility had implemented interventions to address Resident #9's wandering behaviors, which included staff to occupy the resident with chore like tasks, such as folding clothes, making beds and sweeping floors. Continued interview revealed the facility had discussed a locked placement for Resident #9 as his/her wandering had increased and he/she was going in and out of other residents' rooms which the other residents did not like. Interview, on [DATE] at 12:30 PM, with Resident #9's PCP revealed the resident's advanced Dementia prevented him/her from having the ability to follow any directions. Per the PCP, the resident's Dementia contributed to Resident #9's lack of safety awareness making the resident a massive fall risk. He stated he was not notified of any symptoms when the resident returned to the facility on [DATE] and had he been informed the resident had a headache and redness around his/her crown, he would have sent the resident back to the ED to be reevaluated. Additionally, the facility should had implemented the instructions sent from the ED upon the resident's return. Interview with the Medical Director on [DATE] at 1:00 PM, revealed he was not aware of concerns regarding Resident #9, as the resident's PCP was handling the resident's care concerns. He stated even though he was the facility's Medical Director, concerns related to Resident #9 would not have come across his desk. The Medical Director further revealed he was not aware of any discussion by the facility regarding Resident #9 being moved to a locked unit. Additional interview with the facility's Medical Director on [DATE] at 7:30 AM, revealed his expectation was that staff would provide quality care to the facility's residents to ensure they were safe. He revealed safety interventions for residents were to be documented on the residents' care plans. Continued interview revealed he did not get involved with the care of residents who had a PCP. He stated he only became involved in a resident's care who had not been assigned to him, if their PCP was not providing the necessary care for that resident. Interview on [DATE] at 12:45 PM, with the facility's Administrator revealed the facility had investigated Resident #9's death and had been unable to determine if the fall caused the resident's death. 2. Review of Resident #10's closed clinical record revealed the facility admitted the resident on [DATE] with diagnoses that included Unspecified Dementia with behavioral disturbance, Tremor, and repeated falls. Review of the Quarterly MDS Assessments, dated [DATE], revealed the facility assessed Resident #10 to have a BIMS' score of three (3) which indicated he/she was severely cognitively impaired. Continued review of Resident #10's closed clinical record revealed a Fall Risk Assessment document, dated [DATE], noting the facility assessed the resident as having a score of eleven (11), indicating the resident was at high risk for falls. Review of the facility's Careplan Report/At Risk for Falls for Resident #10 revealed a care plan addressing his/her falls. Continued review revealed interventions, dated [DATE], that included, an intervention for Resident #10's bed to be at the lowest level when staff were not providing care. Review of the facility's documentation titled Fall Management for Resident #10 revealed the following information. On [DATE], the facility added a care plan intervention for a fall mat beside the resident's bed, after he/she was found sitting on the floor by the bed and had slid off the side of the bed. On [DATE], the facility added care plan interventions for food and drinks to be offered to the resident, addressing his/her toileting and hygienic needs, and scoop mattress for his/her bed after he/she rolled out of bed onto the floor. On [DATE], the facility added a care plan intervention for psychiatric (psych) services to evaluate the resident for increased restlessness and rambling after the resident was found lying on the fall mat which was on the floor beside his/her bed. Further review of the Fall Management document revealed on [DATE] at approximately 9:05 AM, Resident #10 was found lying on his/her back parallel to his/her bed on the fall mat with his/her leg extended and arms extended by his/her sides. Further review revealed the bed was locked and in low position at this time with call light lying on the bed. Resident #10 was noted to have sporacdic shallow respirations and faint apical heart tones. Face and neck appeared ashen. Oxygen applied and EMS (emergency Medical Services) called. Review of the document titled .Monthlies Report undated, revealed a Treatment Order dated [DATE] for Resident #10 to have a low bed when he/she was in bed to reduce injury related to his/her decreased safety awareness, every shift. Further review revealed a scoop mattress to bed at all times to define parameters of bed related to decreased safety awareness (every shift). Review of the Monthly Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the timeframe of [DATE] through [DATE] for Resident #10 revealed on [DATE], no documented evidence the nurses, assigned to his/her care, ensured the resident's treatment orders and care plan interventions were implemented as required. Continued review revealed no documentation the nurses ensured and noted Resident #10's: scoop mattress to bed at all times to define parameters of the bed related to decreased safety awareness (every shift); his/her fall mat to the exposed side of bed when in bed to reduce injury related to decreased safety awareness (every shift); and the resident's bed to be at lowest level when not providing care for the shift beginning at 6:00 AM on [DATE]. Review of the document titled, Telepsychiatric Evaluation, dated [DATE], revealed the Psychiatrist evaluated Resident #10's Insight/Judgement as poor to nil, and sensorium (the sensory parts of the brain) and orientation as unable to obtain. Review of the facility's unsigned, undated Initial/Final Investigation documentation regarding the fall Resident #10 sustained on [DATE], revealed the facility determined two (2) CNAs positioned the resident for breakfast, with him/her sitting up on the bed, which was in the low position. Continued review revealed approximately fifteen (15) minutes after breakfast, CNA #10, a Medication Aide, entered Resident #10's room to administer his/her medication. Further review revealed CNA #10 reported leaving Resident #10's room with his/her bed in a semi-fowlers position with the bed at the lowest level. Per review of the investigation documentation, another CNA retrieved Resident #10's breakfast tray and reported no change in the resident's status and his/her bed was still in a low positoin. Record review revealed approximately fifteen (15) minutes later, the Activity Assistant (CNA #22) heard what sounded like a mechanical bed moving and upon looking into Resident #10's room, she observed Resident #10 rolling out of his/her bed. Further review revealed the incident was also observed by both Resident #10's roommate (Resident #16) and CNA #1. Review of the investigation documentation revealed Resident 10's roomate, Resident #16 (whom the facility assessed as moderately cognitively impaired) reported Resident #10 had his/her hands on the bed remote control, and moved/raised the bed up, and rolled out of bed. The investigation revealed the facility noted it could not definitively determine what caused Resident #10 to roll out of his/her bed. Record review revealed Resident #16 was Resident #10's roommate. Review of the document titled, MDS Quarterly Review Assessment, dated [DATE] revealed Resident #16 scored ten (10) on the Brief Interview of Mental Status which indicated moderately impaired cognition. Interview with Resident #16, on [DATE] at 10:55 AM, revealed he/she recalled his/her roommate who died . Resident #16 stated Resident #10 raised the bed up all the way and fell out, then he/she just laid there on the floor until they came and got him/her. Interview on [DATE] at 12:40 PM, with CNA #10 revealed at approximately 8:00 AM on the morning of [DATE], she had been in the hall passing residents' medications (meds). She stated she had gone into Resident #10's room and put the head of the resident's bed up and administered his/her medication. Per CNA #10, after administering Resident #10's meds she lowered the head of the resident's bed back down, and placed his/her call light/bed control under his/her pillow where she usually placed it. Continued interview revealed Resident #10's bed was at the lowest level when she left the resident's room. According to CNA #10, about thirty (30) minutes later she was at the nurses' station when CNA #13 came and got her. CNA #10 stated she, CNA #13 and CNA #18 arrived at Resident #10's room, and the DON ran in behind them. Per the CNA, the Assistant DON (ADON) was also in Resident #10's room. Further interview revealed Resident #10's bed was not at the lowest level when she entered the room. When interviewed about Resident #10's call light/bed control the CNA #10 further stated, You never would think that he/she would grab it. The CNA became upset and started crying. CNA #10 further stated, You never want something like that to happen. Interview, on [DATE] at 2:59 PM, with CNA #13 revealed he had been working the floor around breakfast time, and heard the Activities Assistant yell that Resident #10 was on the floor. Per interview, he responded to the Activities Assistance yelling and went to Resident #10's room. Continued interview revealed when he entered Resident #10's room, his/her bed was all the way up in the air and the resident was lying on the floor. Per CNA #13, the Activities Assistant told him Resident #10's bed had been going up by itself. Further interview revealed the CNA was still in Resident #10's room when Emergency Medical personnel arrived. Further interview revealed at some point Resident #10's bed was lowered back to the lowest position; however, the CNA did not know who lowered the bed. Interview, on [DATE] at 3:15 PM, with CNA #21 revealed she and CNA #13 had been picking up residents' meal trays when they heard Resident #10 screaming for help. CNA #21 further stated Resident #10's bed had been all the way up when she and CNA #13 first got to his/her room. CNA #21 stated Resident #10 was definitely not okay and that his/her eyes were rolling back in his/her head. CNA #21 said the ADON and the DON entered Resident #10's room, put oxygen on him/her, and EMS arrived. She said EMS asked the staff to leave the room so the coroner could come. Review of the EMS document noted as Incident #2684, dated [DATE], revealed EMS personnel received the call regarding Resident #10's, [DATE] fall incident at 9:16 AM and was at Resident #10's bedside at 9:22 AM. Per review, the EMS personnel noted their clinical impression of Resident #10's injury on [DATE] as a fall from the bed at two (2) feet (ft) at the nursing home. Further review revealed the EMS personnel noted the primary impression noted as patient unconscious, and intital patient acuity was documented as dead without resuscitation efforts. Interview with the Maintenance Director on [DATE] at 9:36 AM, and review of his written statement, revealed on [DATE] he inspected bed one (1) in room nineteen (19) which had been Resident #10's bed prior to his/her fall and subsequent death on [DATE]. Review of the Maintenance Director's written statement revealed he documented his inspection of all the functions on Resident #10's former bed and all the bed functions had been in working order. Further interview with the Maintenance Director revealed he confirmed the findings noted in his written statement. Phone interview was attempted with CNA #22/ Activities Assistant on [DATE] at 2:52 PM; the attempt was unsuccessful, and no return call was received. Interview on [DATE] at 1:30 PM, with the ADON revealed on [DATE], when she entered Resident #10's room the resident's bed had been all the way down to the floor. However, the ADON stated CNA #22 had seen Resident #10 roll out of bed from the height of all the way up. Per the ADON, the resident's bed was flat when lowered to the floor. The ADON stated when she first walked in Resident #10's room she started assessing the resident. Continued interview revealed her assessment of Resident #10 revealed he/she had a weak pulse, and she went and got oxygen from the crash cart. She stated she knew Resident #10 had a Do Not Resuscitate (DNR) status, so she immediately called Resident #10's family. The ADON stated she called EMS because she thought the resident had felt a weak pulse. She stated she told EMS she had a resident who had fallen from his/her bed at a tall height, and that he/she was a DNR and had a faint pulse. However, further interview revealed when EMS arrived Resident #10 had no pulse. The ADON stated Resident #10 had always moved around a lot and maybe he/she grabbed the bed control causing it to raise up. In addition, the ADON stated Resident #10 had a tendency to grab and hold onto things. She further stated she could not recall if the information regarding the resident's tendency to grab and hold onto things had been on his/her care plan; she stated it should have been. Interview on [DATE] at 6:07 PM, with the DON revealed Resident #10 had advanced end stage Dementia, was confused, and had poor safety awareness. Per the DON, residents were not assessed for their ability to safely use the bed control (which raised and lowered the bed). The DON stated she recalled Resident #10's grabbing behavior; however, there had been no interventions on the resident's care plan related to him/her touching or using the bed control. Interview, on [DATE] at 1:50 PM, with the DON revealed all resident falls were discussed at the facility's clinical meetings. However, she stated she could not recall information of falls from a year ago. Continued interview revealed the DON had determined the facility provided adequate supervision of residents by having staff in the building twenty-four (24) hours a day seven (7) days a week, and multiple interventions in place. Interview on [DATE] at 12:55 PM, with the Administrator revealed Resident #10's death triggered an investigation because it had been witnessed by his/her roommate. Per the Administrator, Resident #10's roommate, Resident #16, witnessed Resident #10 raising his/her bed up in the air and then fall from the bed to the floor. Continued interview revealed there had been nothing that clearly defined what had happened. She stated residents' care plans were important to outline the care the facility was to provide to the resident. 3. Review of Resident #8's closed clinical record revealed the Admission Face Sheet noted the facility readmitted the resident on [DATE], with diagnoses that included Altered Mental Status, other Nondisplaced Fracture of the second cervical vertebra, and a history of falls. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #8 to have a BIMS' score of three (3), which indicated severe cognitive impairment. Review of the Fall Risk Assessment, dated [DATE], revealed the facility assessed Resident #8's fall risk for the first time on that date, seventeen (17) months after the facility readmitted the resident. Continued review of the Fall Risk Assessment, revealed the facility assessed Resident #8 to have a score of eleven (11), which indicated the resident was at high risk for falls. Review of the facility's documents titled, Fall Management for Resident #8 revealed the resident sustained seven (7) falls from [DATE] through [DATE], five (5) of which resulted in injury. Review of the Fall Management document, dated [DATE] revealed Resident #8 attempted to self-transfer and fell , and then complained of head pain. The physician was notified. A Computed Tomography (CT) scan was ordered and the result was clear. Review of the, Fall Management document, dated [DATE], revealed Resident #8 attempted to self-transfer and had a fall. He/she sustatined a small bump on the back of his/her head, and had no pain or discomfort. The physician was notified, and a referral to therapy was made. Review of the facility's document titled, Fall Management dated [DATE] revealed Resident #8 was found in his/her room lying on the floor by his/her wheelchair and complained of right hip and back of the head pain. The physician was notified and Resident #8 was sent out for an x-ray of the right hip and CT scan of his/her head. The results were negative. Review of the f [TRUNCATED]

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 the Physician was notified of a change in condition for one (1) of seventeen (17) sampled residents (Resident #9). Resident #9 sustained a fall on [DATE], was sent to the emergency room (ER) and returned to the facility with a diagnosis of a Subdural Hematoma. Review of the facility's Progress Notes for Resident #9 and interviews revealed the facility did not contact Resident #9's Physician of his/her complaints of a headache, neck pain and redness to the crown of the head after the resident returned to the facility on [DATE]. The facility also failed to contact Resident #9's Physician when the resident was lethargic, not opening his/her eyes, and unable to take medications. On [DATE], Resident #9 complained of a headache to staff, stood up and immediately fell forward onto the floor. The resident was pronounced deceased . The findings include: Review of the facility's policy, Change of Condition Standard of Practice, dated ,d+[DATE], revealed the facility would ensure all interested parties would be informed of a resident's change in health status, which depended on the nursing assessment, so a treatment plan could be developed in the best interest of the resident. The facility would immediately (as soon as possible/no longer than twenty-four (24) hours) inform the resident's physician when there was a significant change in the resident's physical, mental or psychosocial status (deterioration of health, life-threatening or clinical complications). The facility would also notify the physician if the resident had an accident that resulted in injury which could potentially require the physician's intervention. Review of Resident #9's closed clinical records revealed the facility admitted the resident on [DATE] with diagnoses of Unspecified Dementia with behavioral disturbances, age related osteoporosis and spondylosis. Review of Resident #9's Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #10 was noted with a Brief Mental Interview Status of three (3) out of fifteen (15) severe cognitive impairment. The resident was noted to have hallucinations, no behaviors present, and did not reject care. The resident wandered throughout the facility one (1) to three (3) days in look back period. The wandering was noted with zero risk but documented as intrusive to other residents. Continued review of the Admission MDS, revealed Resident #10 required set-up only for bed mobility, to walk in the room, walk in the corridor, locomotion on/off the unit, to get dressed, to eat and to use the bathroom. The resident was documented to be a one (1) person physical assistance for transfers and personal hygiene. Additionally, the Admission MDS, revealed the resident was not steady but was able to stabilize without human assistance when he/she moved from seated to standing position, walking if used assisted device, to turn around and face opposite direction and for surface-to-surface transfer. Resident #10 was noted to be free from lower and upper extremity impairments. No assistance devices were checked for use by the resident. Review of Resident #9's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of three (3) out of fifteen (15), which indicated severe cognitive impairment. The facility assessed the resident to wander one (1) to three (3) times per day. The facility assessed Resident #9 to require supervision and oversight to transfer, walk in the room, and for locomotion in the corridor and on/off of the unit. The facility assessed the resident to require the limited assistance of one (1) staff for bed mobility and to get dressed. The facility also assessed the resident as an extensive assistance of one (1) staff to use the toilet and for personal hygiene. Closed record review of Resident #9's Comprehensive Care Plan (CCP) established on [DATE] for ADL care revealed the resident was to be monitored for ADL performance and staff were to watch for a change of status. Resident #9's Fall Care Plan was established on [DATE], related to the resident's weakness, decreased safety awareness and history of diagnoses. Interventions, dated [DATE], were to put the resident's bed against the wall, ensure proper footwear/nonskid socks were in place, pathways clear of obstructions, remind resident to use the call light and answer it promptly, provide assistance with ADLs, proper lighting, help with toileting and Physical, Occupational or Speech Therapy as needed. On [DATE], the facility added the intervention to have the resident assessed by therapy for ambulation. However, the resident passed away on [DATE]. Closed record review revealed the facility's Fall Event, dated [DATE] at 1:50 AM, revealed Resident #9 had a fall and hit his/her head, which resulted in a large knot on the back of his/her head. The facility assessed Resident #9 and sent him/her out to the Emergency Department (ED). Closed record review of Resident #9's Progress Notes, revealed the facility readmitted the resident from the hospital, on [DATE] at 7:30 AM. Further review revealed care instructions for a subdural hematoma were sent from the ED to the facility when Resident #9 returned on [DATE]. Continued review revealed the instructions stated the doctor should be contacted if the resident could not stay awake; had a headache that got worse; or had trouble concentrating and/or had a change in mood. The aftercare instructions noted additional symptoms could be neck pain. Closed record review revealed upon return to the facility the resident complained of a headache. Review further revealed Licensed Practice Nurse (LPN) #1 noted the resident was to have a follow up CT (computerized tomography) scan in one (1) month. Further review revealed Resident #9 complained of neck and back pain. LPN #1 gave the resident pain medication as ordered with positive results. Review of the Progress Note, dated [DATE] at 2:31 AM, revealed the Director of Nursing (DON) noted Resident #9 was somewhat aggressive, continued to complain of neck pain and had redness noted to the crown of his/her head. Additionally, she noted Resident #9 required a two (2) person physical assist to be transferred this evening. Review of the Progress Note, revealed the DON documented Resident #9 could not recall the fall that happened to him/her on the prior day. However, further review revealed no documentation the facility notified the Physician of the changes in the resident's condition. Review of Resident #9's Progress Note, dated [DATE] at 5:37 PM, completed by Licensed Practical Nurse (LPN) #1, revealed the resident slept all shift, but responded to stimuli and spoke when spoken to. Continued review revealed no documentation the Physician was notified of the change in the resident's condition. Review of Resident #9's Progress Note, dated [DATE] at 9:03 PM, completed by Registered Nurse (RN) #1, revealed the resident slept all shift. Record review revealed no documentation the facility notified the Physician. Review of Resident #9's Progress Note, dated [DATE] at 9:52 AM, completed by LPN #1, revealed the resident continued to be lethargic and nursing staff held the resident's pain medication again. Continued review revealed Resident #9 would not open his/her eyes when talking. Further review revealed Resident #9's Physician was notified and informed that the resident was lethargic, and the pain medication was held until further notice. Closed record review revealed LPN #5 noted on [DATE] at 1:10 AM, that Resident #9 slept all shift, and spoke when spoken to. However, the resident did not make much sense. LPN #5 noted she was unable to get Resident #9 to take his/her medication. Continued review revealed no documentation the facility notified the Physician of the change in the resident's condition. Record review revealed Registered Nurse (RN) #2, noted on [DATE] at 10:46 PM, that Resident #9 slept most of the shift and continued to be lethargic. The Note stated Resident #9 did not attempt to get out of bed or wander the halls as usual. Further review revealed there was no documentation the facility notified the Physician of the change in the resident's condition. Interview with Licensed Practice Nurse (LPN) #1 on [DATE] at 3:30 PM, revealed there was no way to monitor Resident #9's baseline. She stated when a resident required additional monitoring, it would be noted on a daily log, which was written in pencil and erased when it was done. LPN #1 stated it was normal for the resident to sleep all day and then be up for twenty-four (24) hours, to be agitated and to require two (2) staff for a transfer. She stated she did not consider the need to send Resident #9 back to the emergency room (ER) because the resident was in a steady decline related to Dementia. She thought the PCP (Primary Care Physician) was going to place the resident in palliative care. LPN #1 also stated the paperwork sent back from the ER for the resident was not instructions, but just information and therefore not entered as an order. Interview with Registered Nurse (RN) #3, on [DATE] at 11:00 AM, revealed a change in condition was when a resident's vitals changed, blood pressure changed, breathing, behaviors, any acute change and if the resident refused to take medication. She stated the doctor was to be contacted anytime a change occurred. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:30 PM, revealed she reviewed documentation when a resident returned from the ER. She looked over the orders, for follow-up appointments and treatment needs. The DON stated if a resident had a change in condition, he/she would be assessed to determine any changes from the baseline and anything off the baseline the doctor would be notified. However, if staff were not sure about the outcome, they should contact management to discuss their concerns. Interview with the DON, on [DATE] at 3:45 PM, revealed it was the facility's expectation the doctor was to be notified when a resident had a change in condition. She also stated if there was an PRN as needed order, staff could provide services first and then call the doctor, she gave an example of breathing treatments. The DON also stated nurses were able to determine if a medication should be held and there were parameters for which the doctor needed to be notified. Interview with the ER Doctor on [DATE] at 11:15 AM, revealed when Resident #9 complained of a headache, was lethargic and noted to have redness around the crown of his/her head she would have been concerned the subdural hematoma had gotten bigger. Continued interview revealed these symptoms would have been reason to send the resident out for a reevaluation. The ER Doctor stated there was nothing about this resident that made her, or the Neurosurgeon believe Resident #9 was at end of life. She also stated the only reason she felt comfortable to send Resident #9 back to the facility was because the facility had skilled care provided twenty-four (24) hours per day. Interview with the PCP, on [DATE] at 12:30 PM, revealed he did not recall notification of Resident #9's complaints of a headache after he/she returned from the hospital. He stated if it was not documented in Progress Notes, he was not notified. Resident #9's PCP also stated the facility did not provide documentation from the ER that a Neurosurgeon was consulted by the ER doctor and Resident #9 was scheduled for another CT scan in one (1) month. He also stated he was not contacted on [DATE] when the Director of Nursing (DON) observed redness to the crown of Resident #9's head with complaints of neck pain. Interview with the Medical Director (MD) on [DATE] at 2:00 PM, revealed he was not involved in Resident #9's care. He stated he was only responsible for the residents in the facility assigned to his care. The Medical Director stated if the resident had a PCP who was present and provided services, he did not oversee the case. However, in relation to a change in condition, the facility's policy was to be followed. He stated a phone call or a fax would be necessary to the PCP/MD if there was a change in mental status, any falls or if a resident refused medication. Interview with the Administrator on [DATE] at 12:54 PM, revealed the ADON and DON were responsible to monitor to ensure floor staff handled changes in condition appropriately. The ADON and DON were not required to contact her; but they were to contact the PCP/MD as events occurred. 44486

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free from accidents and/or hazards for one (1) of four (4) sampled residents, Resident #1. Resident #1 exited the facility unsupervised on 05/03/19 at 9:00 PM and was found on the sidewalk in front of the facility by staff. Observation and interviews revealed the alarm to the door from which the resident exited could only be heard in the area of the door and not anywhere else in the facility. The findings include: Review of the facility's policy, Resident Elopement, undated, revealed interventions were put in place to prevent elopement. The process for elopement included to respond to a door alarm and the alarm was to remain activated if it was not evident the cause of the alarm. Staff was to be notified of a potential elopement and the perimeter of the facility was to be evaluated by the staff. Review of the facility's policy, Safety and Supervision of Resident, revised (MONTH) 2007, revealed a facility goal was to make the residents' environment free from accidents and hazards. The facility identified safety and environmental risks and hazards through a combination of training, monitoring, and reporting. The facility was committed to the safety of the residents at all levels within the organization. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/19/19, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) and determined the resident was interviewable with a score of ten (10) of a possible fifteen (15). The facility assessed the resident required supervision by one (1) staff for walking in the corridor and extensive assistance of one (1) staff for locomotion on and off the unit. Per the MDS, the resident did not display wandering behavior. Review of a facility Investigation, dated 05/03/19, revealed on 05/03/19, Resident #1 exited the facility without staff knowledge and walked down the sidewalk and fell . The resident did not sustain injury. Interview with Resident #1, on 05/21/19 at 10:00 AM, revealed he/she kicked the bottom of the door while pushing on the door handle, which allowed the door to open. Resident #1 stated he/she fell because the ground was uneven, and eventually laid down because he/she got tired of waiting for someone to come and assist him back into the facility. Interview with the Director of Nursing (DON), on 05/21/19 at 10:35 AM, revealed the nursing administration team was in the office working on chart audits on 05/03/19 at 9:00 PM when a Certified Nursing Assistant (CNA) came and informed the team Resident #1 left the facility. Per the DON, the facility reviewed the video footage, which showed Resident #1 stood up from the wheelchair, stepped to the door, pushed twice on the handle, and on the third attempt to push the handle, he/she used his/her foot and pushed the bottom foot plate and the door opened and the alarm was activated. The video showed Resident #1 walk through the door and around the corner of the facility on the sidewalk, and about a minute later, a CNA who was not assigned to work walked to the door, deactivated the alarm, and left the porch. Interview with CNA #4, on 05/22/19 at 9:48 AM, revealed she was assigned to Resident #1 the night of 05/03/19, and Resident #1 was on the porch in a wheelchair directly next to the exit door. She stated she went to get linen and when she returned to get Resident #1 for a bath, the wheelchair was empty. She immediately told her co-worker to go get the DON and she went out the exit door and found Resident #1 in the middle of the sidewalk on the ground. The CNA stated she did not hear the door alarm while she was in the hallway. Interview with CNA #5, on 05/22/19 at 10:24 AM, revealed on 05/03/19 at 9:00 PM, she did not hear the door alarm on her unit when Resident #1 left the facility. She stated staff was able to hear the elopement alarm all over the facility, but not the regular exit alarm. She stated the regular exit alarm was too low to hear down the hallways. Observation, on 05/23/18 at 8:53 AM, revealed the Administrator activated the door alarm; however, the Surveyor could not hear the alarm in any location on the West or East Halls. Interview with CNA #1, on 05/23/19 at 8:58 AM, revealed when the Administrator activated the door alarm, she did not hear the alarm while she stood on the West Hall. The CNA stated there was no way she could hear the regular door alarm in the hallway, but she was able to hear the elopement alarm because it came through the announcement system. Interview with Licensed Practical Nurse (LPN) #4, on 05/22/19 at 9:18 AM, revealed when Resident #1 exited the facility, she was at the end of the hallway and did not hear the door alarm. She further stated she told the DON she did not hear the door alarm during her interview with the DON. Interview with LPN #5, on 05/22/19 at 10:44 AM, revealed when Resident #1 exited the facility, he was in the process of administering medication and did not hear the alarm and informed the DON. Interview with Unit Manager (UM) #2, on 05/22/19 at 11:08 AM, revealed she was in the office when Resident #1 walked out of the facility and stated she did not hear an alarm sound. Interview with the Maintenance Director, on 05/22/19 11:57 AM, revealed he monitored and audited the function of the alarm. However, he stated he did not audit whether staff could hear the alarm throughout the facility. The Director revealed the exit alarms were not audible through the intercom system like the elopement Wanderguard system. He further stated staff probably could not hear the exit alarm as the alarm was soft in tone and volume. Interview with the Assistant Director of Nursing (ADON), on 05/23/19 at 2:49 PM, revealed she was in the nursing office on 05/03/19 at 9:00 PM when Resident #1 left the facility. She stated no one in the office heard the regular exit alarm. The ADON stated staff was unable to hear the regular door alarm unless they were right within the area. Because staff was unable to hear the door alarm, she stated anyone could gain access to and leave the facility without the staff aware. Continued interview with the DON, on 05/23/19 at 10:22 AM, revealed the door alarm did not go over the intercom, and was not loud enough to hear anywhere except the front lobby area. She stated residents were allowed to sit in the lobby and porch area and staff was not assigned to supervise the residents in these general areas. She stated the facility was responsible for the safety of all residents at all times. Interview with the Administrator, on 05/23/19 at 9:00 AM, revealed the alarm for the front exit door could not be heard from his office, which was at the end of the East Hall. He stated the alarm was too soft to be effective and was not part of the announcement system like the elopement alarm. He further stated the door alarm was to alert staff the door was opened without the key code to unlock the door, and was for the safety of the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure timely care and services were provided to a resident to treat a Urinary Tract Infection [MEDICAL CONDITION] for one (1) of sixteen (16) sampled residents, Resident #47. Record review and interviews revealed on 11/17/18, Resident #47 complained of bladder pain, presented with a fever on multiple days, was noted to have increased confusion, and experienced falls. The resident was not evaluated for a UTI until 11/22/18, which resulted in the UTI to worsen and the resident experienced a fall and required hospitalization due to fractures from the fall. Resident #47 returned to the facility and was totally dependent on staff for care, when prior to the fall, the resident was independent. The findings include: Review of the facility's policy, Urinary Tract Infections/Bacteriuria/Clinical Protocol, revised (MONTH) 2006, revealed signs and symptoms of a UTI were to be identified as soon as possible to begin treatment. Staff was to notify the Medical Director (MD) of residents who exhibited a fever. A fever was identified as over 100.4 degrees Fahrenheit (F). Continued review revealed in order for the facility and MD to make an empirical [DIAGNOSES REDACTED]. Notification to the MD of the presence of a fever with other identified complaints or findings was completed for the MD to interpret the signs and symptoms of a possible UTI and conclude the course and treatment for [REDACTED]. Review of the facility's policy, Acute Condition Changes (ACC) Clinical Protocol, revised date (MONTH) 2010, revealed staff was to call MD, who attended to the care and services for the resident with the identified ACC, and were to include current symptoms and status. Lab results were to be reported to the MD when available. The MD was to determine and authorize appropriate treatment for [REDACTED]. Further review revealed an ACC could be managed effectively in the facility with outcomes comparable to those who were hospitalized . Review of the facility's McGreer Pathway for Infection Surveillance, undated, revealed for a UTI without a catheter, two (2) criteria were to be present to consider surveillance for a UTI and included fever and supra pubic pain. A UTI was to be diagnosed with [REDACTED]. The facility was to obtain a urine sample with MD order with the presented symptoms as a diagnostic tool. Review of the McGreer definition of fever, dated (MONTH) 2012, revealed a fever was a temperature greater than 100.4 F and was consistent with the 2008 Infectious Disease of America (IDSA) guideline for the evaluation of fevers and infection with older adults in a Long Term Care facility. Review of the Resident #47's clinical record revealed the facility readmitted the resident on 11/30/18, with the [DIAGNOSES REDACTED]. Review of Resident #47's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15) and determined the resident interviewable. The facility determined Resident #47 required supervision with set up help for Bed Mobility, Transfers, Walking, Locomotion, Dressing, Eating, Toilet Use, and Personal Hygiene. Resident #47 was always continent of bladder and bowel. Further review revealed Resident #47 did not receive scheduled pain medication management and denied pain. Review of Resident # 47's Medication Administration Record [REDACTED]. Documentation revealed a dose was given on 11/20/18 at 11:35 AM and 11/22/18 at 4:10 PM. In addition, the MAR indicated [REDACTED]. Documentation revealed Resident #47 received a dose, on 11/22/18 at 3:02 PM, for a temperature of 101.7 F, and again on 11/24/18 at 4:17 PM for a temperature of 100.2 F. Review of Resident #47's Nurses' Notes, dated 11/17/18 at 5:42 AM, revealed the resident complained of bladder pain and held his/her area of the lower abdomen. The resident reported the symptoms started several days prior to the notification. Nursing staff obtained a urine sample to perform a dipstick test (dipstick test is a basic diagnostic tool used to determine changes in a urine) and results revealed trace leukocytes and positive for [MEDICATION NAME] (The dipstick test for [MEDICATION NAME] is a rapid screening method for possible asymptomatic infections caused by [MEDICATION NAME]-reducing bacteria. Some bacteria species that most commonly cause UTIs like Escherichia coli have enzymes that reduce the [MEDICATION NAME] present in urine to [MEDICATION NAME]). The results were faxed to the MD's office. Nursing staff noted follow-up was to occur next shift after report to day shift and nursing staff would continue to monitor the resident. Review of MAR indicated [REDACTED]. However, continued review of nursing note documentation did not reveal nursing staff monitored the resident for potential UTI symptoms, until 11/20/19. Nor did nursing staff follow-up regarding the faxed results sent to the MD's office regarding the urine dipstick results. Review of Nurses' Notes, dated 11/20/18 at 11:32 AM, revealed Resident #47 complained he/she felt cold and had an oral temperature of 101.2 F. Licensed Practical Nurse (LPN) #4 noted she administered medication to reduce the fever and would monitor the resident. Continued review of nursing notes revealed no resident assessment regarding previous reported bladder pain or other UTI signs or symptoms. Continued review revealed LPN #4 noted, at 2:26 PM on 11/20/19, the resident felt better and temperature was 98.3 degrees and nursing staff would continue to monitor, however, no further nursing assessments were documented as conducted on 11/20/19. Review of Nurses' Notes, dated 11/21/18 at 3:34 AM, revealed nursing staff observed the resident shaking and noted the resident's clothing and bed linen were wet with sweat. LPN # 5 noted the resident's clothes and bed linens were changed. LPN #5 documented the resident was afebrile and had previously received medication as ordered. At 4:04 AM, the resident complained he/she felt cold and had an oral temperature of 100.5 F, was shaking and continued to complain he/she felt cold. Continued review of Nurses' Notes for 11/21/18, revealed at 5:06 AM, LPN #5 found the resident on the floor. The resident had a fever and felt un-well and stated he/she was unsure what caused the fall. Vitals signs were assessed with [REDACTED]. At 4:10 PM, LPN #4 noted the resident was given [MEDICATION NAME] rectally because Resident #47's temperature was 102.0 F and previously vomited oral medication. Review of Nurses' Notes, dated 11/22/18 at 2:35 PM, revealed Resident #47's complained of a chill, headache, and stomach and body aches. The resident's temperature was 101.7 F. Staff administered medication for the fever, notified the responsible party, and monitored the resident. At 3:38 PM, the resident was found on the floor and he/she stated he/she attempted to get out of bed and lost his/her balance. The nurse noted the resident was sick and weak. The MD was notified and orders for a Flu test was obtained. Further review revealed the MD was notified at 4:48 PM of a negative Flu test. The MD ordered a Urinalysis (UA) with a Culture and Sensitivity (C&S) and to notify of the results. Review of Resident #47's UA Results, dated 11/22/18 at 9:16 PM, revealed the results were cloudy, specific gravity was marked abnormal with 1.010, abnormal presence of blood, abnormal protein presence in the urine, abnormal presence of Leukocytes (cells present with infections), abnormal Urine Red Blood Cells (URBC) and Urine White Blood Cells (UWBC), and abnormal high presence of bacteria in the urine. The results were faxed to the provider on 11/22/18, as noted on the lab result page. Review of Resident #47's Nurses' Notes, dated 11/23/18 at 1:22 AM, revealed staff reported to LPN #7 the resident was unable to walk from the bathroom and the resident stated he/she was hot, was cold, and very sick. The resident was assessed and his/her temperature was 102.6 F with a pulse rate of 123 beats per minute. The resident also had dry heaves. The MD was notified of his/her condition as well of the lab results at this time. LPN #7 noted the MD ordered antibiotics and if there was no change in status to send to the emergency room (ER) for evaluation and treatment. Review of Resident #47's Urine Culture, dated 11/25/19 at 8:03 AM, revealed Escherichia Coli (E Coli - bacteria found in the intestines) was found in the urine when cultured. Review of Nurses' Notes, dated 11/26/18 at 1:30 AM, revealed Resident #47 was found on the floor and on his/her back and stated to LPN #7 he/she was engaged in a conversation with someone in the room, became distracted, and fell . The resident was assessed and had a skin tear to the back of the right arm. The MD was notified with orders received for a mobile x-ray. The resident was reeducated to use the call light and not to get up without assistance and staff provided additional fall mats to the bedside. At 5:34 AM, LPN #7 sent the resident to the ER related to the resident's complaint of increased hip pain. Review of Resident #47's Hospital Discharge Summery, dated 11/30/18, revealed the resident was discharged with [DIAGNOSES REDACTED]. Resident #47 was also diagnosed with [REDACTED]. The resident was noted to have urine retention with the admission and when the resident was sent to the ER, he/she was under treatment for [REDACTED]. Observations, on 03/27/19 at 11:00 AM and 03/28/19 at 2:30 PM, revealed Resident #47 was in his/her room in a Broda chair faced toward the window with eyes closed, and a position alarm clipped to his/her shoulder. Attempts to arouse the resident were unsuccessful. Interview with Family #5, on 03/29/19 at 12:43 PM, revealed prior to the UTI and fall, Resident #47 was completely independent with the exception of supervision and minimal assistance, was alert, active, and carried a conversation easily with the exception of memory issues. She stated after the late [DIAGNOSES REDACTED].#47 required total assistance with the exception of self-feeding with oversight. Family #5 revealed the resident had multiple days of high fevers and she felt nothing was done to find the source of the fever. She stated the resident was in constant pain because the fractures were not healed and would not heal, and was more confused. Per interview, the resident was not a surgical candidate and therefore unable to walk as he/she was unable to bear weight. Interview with LPN #4, on 03/29/19 at 9:31 AM, revealed staff did not report fluctuations of fevers or previous reports of bladder pain for Resident #47. She stated the delay of notifying the MD of a resident's change in condition could result in the condition to worsen and later cause the resident to become septic due to the fragility of the residents. LPN #4 stated Resident #47 was independent and sociable before the fall, and was now dependent for all care and services, and received scheduled pain medication as the fracture to his/her hip area would not heal. Interview with LPN #3, on 03/29/19 at 10:04 AM, revealed the MD and facility set a daily schedule for phone conferences to discuss resident concerns, usually twice a day. She stated if there was an emergency, then the facility would call the MD immediately, but it had to be a true emergency and a fever was not considered an emergency. However, she was not sure fevers were relayed as a concern to the MD, and Resident #47 was not monitored for UTI symptoms and she was not previously aware of any complaints by the resident of bladder pain. The LPN stated when the facility obtained the UA after the MD was notified was the first time the topic of a UTI was mentioned. She stated Resident #47 was fully independent before he/she got sick, and now the resident was highly confused and fully dependent on staff. She stated the resident was unable to independently go to the bathroom and now used a brief. She stated the facility educated with annual online in-services on assessments of the residents and UTI signs and symptom; however, she was unaware of the McGreer pathway. Interview with LPN #7, on 03/29/19 at 12:08 PM, revealed when Resident #47 complained of bladder pain, she obtained a urine sampled and completed a urine dip to see if there was in infection, and faxed the results over to the MD's office. However, she did not follow-up if the information was reviewed or relayed to the MD. She stated fevers were not an emergency and she would not notify the MD in the middle of the night of a fever when she was able to provide medication to address the issue. She further stated she was unaware Resident #47 continued to exhibit fevers after the initial complaint of bladder pain but was aware the resident did not feel well. She continued to state she was not aware of the order to send the resident to the ER if the resident was not improved after the start of the antibiotic. She stated Resident #47 was ill from the UTI and was clearly weak when he/she presented on 11/23/18 as unable to walk back unaided from the bathroom. She stated the resident now, was either in bed or the chair because the resident could not walk and was fully dependent for all care areas. Interview with the MD, on 03/29/19 at 2:02 PM, revealed he was unsure if the facility notified him of Resident #47's temperature fluctuations or complaints of bladder pain. However, he stated he would have ordered tests for a temperatures above 100.5 F because a fever with an elderly resident usually meant an infection was present, and if the record did not reflect orders or notification, then he was not notified to request lab or treatments. He further stated the facility conducted twice a day phone conferences to discuss residents needs and concerns but he would want to be notified of a high fever after staff initially addressed the change of condition. The MD stated he did not set parameters for notification with vital signs unless it was indicated for medications; however, he stated it was standard care to call for temperatures, especially with multiple excessively high temperatures in an elderly resident. He further stated late treatment of [REDACTED]. He stated Resident #47 was fully dependent on the nurses for his/her care needs now, and before the fall, the resident was independent. Interview with the Unit Manager (UM), on 03/29/19 at 10:24 AM, revealed the facility did not have protocols for vital sign parameters and when to call the MD, because it has not been an issue. She stated fevers were not considered an emergency and staff thought Resident #47 had a [MEDICAL CONDITION], which was present in the facility and felt he/she was properly monitored. However, she was not aware the resident complained of bladder pain. She stated Resident #47 was independent with all areas and was very social prior to the fall and now the resident was completely dependent for all care needs, was unable to walk, and continued to decline. Interview with the Assistant Director of Nursing (ADON), on 03/29/19 at 2:20 PM, revealed the facility conducted twice a day phone conferences with the MD to discuss resident needs. She stated the facility vital sign protocols did not include parameters, and it was up to the MD to set vital sign parameters for notification. She stated the facility was aware of Resident #47's elevated temperatures but assumed the resident had been exposed to the [MEDICAL CONDITION] present in the facility. The MD was not notified of the high temperatures the resident experienced and she was unaware the resident presented earlier with complaints of bladder pain. She further stated delayed notification and care/services could affect the resident physically and affect the resident's health. She stated Resident #47 was an active resident and now was fully dependent on staff for all care needs, could not walk, was unable to socialize. Interview with the Director of Nursing (DON), on 03/29/19 at 2:46 PM, revealed the facility assumed Resident #47's fevers were associated with a [MEDICAL CONDITION], which caused Resident #47's treatment delay and UTI to worsen. She revealed the facility used the McGreer Pathway for UTI care and services and the facility was responsible to ensure residents received the highest level of care while in the facility. Per interview, Resident #47 previously was up and about and was independent with minor oversight, and now was completely dependent on staff for all care needs, slept most of the time, was unable to walk, and was in constant pain. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed the facility was to ensure residents received timely care and services to manage symptoms and known diseases. He stated Resident #47 was up and about in the facility prior to the fall and now was totally dependent for all care needs. He stated the facility was responsible to meet all resident care needs and services.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician and the resident's responsible party when there was a change in condition for one (1) of sixteen (16) sampled residents, Resident #47. Resident #47 developed a fever, had complaints of pain, fell , and was transferred to the emergency room ; however, the facility did not notify the physician or responsible party of the incidents. The findings include: Review of the facility's policy, Acute Condition Changes (ACC)-Clinical Protocol, revised (MONTH) 2010, revealed staff was to call the attending physician or on call physician with an identified ACC, and were to include current symptoms and status of the resident. The staff was to report to the physician possible causes related to the current symptoms or known test results. If lab results were not available, the facility and physician were to determine if an order for [REDACTED]. Review of the facility's policy, Charting and Documenting, dated (MONTH) 2008, revealed staff was to document notification of family, physician, or staff. Review of the facility's policy, Making an Emergency Transfer or Discharge, revised (MONTH) 2007, revealed when an emergency transfer was initiated, the facility was to notify the resident's physician and notify the resident's representative/responsible party. Review of Resident #47's clinical record revealed the facility readmitted the resident after a hospital stay on 11/30/18, with [DIAGNOSES REDACTED]. Review of Resident #47's Nurses' Note, dated 11/17/18 at 5:42 AM, revealed Licensed Practical Nurse (LPN) #7 documented the resident complained of bladder pain while holding his/her lower abdomen. LPN #7 documented the responsible party was notified; however, did not notify the physician. A urine sample was obtained and the results faxed to the physician. Review of Nurses' Notes, dated 11/20/18 at 11:32 AM, revealed LPN #4 documented the resident complained he/she felt cold and the oral temperature was 101.2 degrees Fahrenheit (F). LPN #4 did not document physician or responsible party notification regarding the elevated temperature. Review of Nurses' Notes, dated 11/21/18 at 4:04 AM, revealed LPN #5 documented the resident complained he/she felt cold and the oral temperature was 100.5 F. There was no documentation the physician or responsible party was notified of the abnormal temperature. At 5:06 AM, the nursing note stated LPN #5 found the resident on the floor and the resident had a fever and felt un-well. LPN #5 did not document she notified the physician. At 4:10 PM, LPN #4 noted the resident was given [MEDICATION NAME] (Tylenol-for fever reduction) rectally because the resident's temperature was 102 F. LPN #4 did not document she notified the physician or responsible party about the resident's abnormal temperature. Continued review of Nursing Notations, revealed at 2:35 PM, LPN #6 noted the resident's temperature was 101.7 F, and the family was aware; however, there was no documentation the physician was notified. Review of Nurses' Notes, dated 11/23/18 at 1:22 AM, revealed LPN #7 documented the resident's temperature was 102.6 F, the resident had yelled out I'm hot, I'm cold, and I am so sick, and had dry heaves. The physician was notified of condition and ordered if there was no change in status to send to the emergency room (ER) for evaluation and treatment. There was no documentation the responsible party was notified. Review of Nurses' Notes, dated 11/26/18 at 1:30 AM, revealed LPN #7 found Resident #47 on the floor on his/her back. The resident said he/she was engaged in a conversation with someone in the room, became distracted, and fell . The physician was notified and x-rays were ordered for the pelvic region. Documentation revealed the responsible party was not notified and was to be notified in the morning. At 5:34 AM, LPN #7 sent the resident to the ER related to complaints of increased pain at his/her pelvic region. LPN #7 did not document the order to send the resident to the ER, nor document notification to the physician or responsible party. The facility could not provide an order to transfer Resident #47 to theER on [DATE]. Interview with LPN #4, on 03/29/18 at 9:31 AM, revealed staff was to call the physician and responsible party immediately when there were changes in a resident's condition. She stated the facility protocol for fevers was utilized when residents presented with a fever and the as needed (PRN) medications were to be administered as ordered, the resident was to be monitored every four (4) hours, and by the end of the day, the physician was called if the fever or condition did not improve. LPN #4 stated she used her judgement as to when to call the physician for fevers, and when a resident presented with a fever of 102 F or 103 F, and the PRN medication for fevers was effective, she would not call the physician. LPN #4 further stated the facility and physician did not identify parameters for temperatures of when to notify the physician or responsible party, and she would not call a family in the middle of the night. The physician was to be called for changes in condition; however, she had not received in report regarding a fever with Resident #47. Per interview, everyone was responsible for the residents' welfare, which included notifications and failure to notify the physician could result in the resident's condition to worsen and become septic (severe infection) due to the fragility of the residents. She stated the facility did not provide in-services on notifications or changes in resident condition. Interview with LPN #3, on 03/29/19 at 10:04 AM, revealed the physician was the Medical Director and the facility phone conferenced with the physician twice a day for updates on residents, and the times were prescheduled in the late morning and afternoon. LPN #3 stated the Unit Manager (UM), Assistant Director of Nursing (ADON), and the Director of Nursing (DON) were to have the phone conference and they learned about resident needs through shift report or when rounds were made. She stated if the information was not passed along in report, then she was unsure how the physician was notified of changes. She stated when the UM, ADON, or DON conference call was completed, the facility was to document in the residents chart of the notification since it's the facility decision to only have two (2) conference calls a day with the physician. According to the LPN, the physician was to be notified of resident changes and if the issue were an emergency, the facility would call immediately; however, she did not consider a 102 F temperature an emergency. She would not call the family at night for a fever and was unsure if the next shift would know to notify the family of the change of condition. Per interview, delayed notification could result in the resident to further decline, and with elderly, it did not take much for decline to occur. She continued and stated she would be very upset if the facility did not call her with a fever or change of condition for her family member. Interview with the UM, on 3/29/19 at 10:24 AM, revealed the person on call was to receive report from the units as to condition changes and resident needs. She stated the Medical Director, who was Resident #47's physician, completed a conference call twice a day to discuss lab results, needs, and illnesses that could wait. After the phone conference, orders were placed on an order sheet and given to staff. She stated she documented in the chart after the phone conference but was unsure about what the others did after the phone conferences. According to the UM, the facility did not have protocols for vital sign parameters and when to call the physician or family as it has not been a previous issue. The UM stated staff was to notify the physician in emergency events or incidents, and notify the family when a resident was sent out of the facility. She stated it was the nurse on duty's responsibility to notify the physician and family as soon as possible, and if not done, it would be very stressful to the resident and family. Interview with LPN #7, on 03/29/19 at 12:08 PM, revealed the physician and family were to be notified with conditions that were out of normal range for a resident. However, she stated physician notification depended on the situation because the Medical Director was notified twice a day, unless it was an emergency. She stated when Resident #47 complained of bladder pain, she obtained and completed a urine dip to see if there was in infection. She stated she faxed the results over to the physician's office but did not see any new orders when she returned the next day. She was assigned to Resident #43 when the resident fell and resulted in the transfer to the ER. She stated Resident #47 refused immediate transfer to the ER and she called the physician and obtained an order for [REDACTED].#47 to the ER because of the intensity of the pain. LPN #7 stated she sent the physician a notice of transfer through the electronic system and the physician was not contacted. Per interview, staff was to notify the physician of condition changes as well as the responsible party immediately and delay in notification could allow the resident to become ill and get hurt. Interview with Family #5, on 03/29/19 at 12:43 PM, revealed the facility did not notify her of Resident #47's multiple events in (MONTH) (YEAR). She stated she found out Resident #47 was transferred to the ER when the ER called her to see if she was on her way to be with the resident. She stated she was very upset and angry and stated the DON apologized for the failure to notify her; however, it did not fix the issue of continued lack of communication by the facility. Interview with the Medical Director, on 03/29/19 at 2:02 PM, revealed he could not remember if the facility notified him of Resident #47's temperature fluctuations. However, he stated he would have ordered tests for a temperature of 102 F and if orders did not reflect this or documented, then he was not notified. He stated he was not notified of Resident #47's transfer to the ER until later in the day during the scheduled phone conferences he held with the facility. He stated he expected the facility to notify him of changes of conditions with any resident. Interview with the ADON, on 03/29/19 2:20 PM, revealed in the morning, the administrative staff gathered new orders, reviewed nurses' notes, the on-call phone notification, and the nurse who was on call reviewed changes and/or needs of residents with the Medical Director during phone conferences twice a day. She stated the facility's vital sign protocols did not include parameters, and the physician set parameters for notification. The ADON further stated acute changes of condition, and falls were a cause of an immediate notification to the physician and the facility was to notify the responsible party of a change of condition, fall, or transfer to an ER. She stated the responsible party was the voice of the residents who could not make choices or decisions on their own, and it was policy to notify the responsible party of changes in condition. She further stated it could affect the resident physically with a delay of treatment and emotionally if the family was unaware of changes which effected the resident's health. She stated the facility in-services did not include notification or changes of condition assessments and notification. Interview with the DON, on 03/29/19 at 2:46 PM, revealed the nurse was to identify changes of condition and notify the physician and responsible party. She stated immediate notification to the physician included increased confusion and fever. The facility did not have a policy or parameters for when to call the physician for vital signs, only when the physician wrote orders for parameters for notification, which were usually for blood pressure. The DON further stated if a resident's temperature was above 101.5, staff should notify the physician and responsible party. She revealed she instructed LPN #7 to call the responsible party when Resident #47 was transferred to the ER; however, LPN #7 did not complete the notification. When she interviewed LPN #7 with the complaint from the responsible party, LPN #7 said she forgot to notify the responsible party. She further stated the nurses were to notify the physician and responsible party at the time the change in condition, or transfer, occurred as it could affect whether the resident received appropriate and timely treatment. She continued to state she audited staff notification with daily review of the residents' clinical records. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed the facility identified one or two isolated incidents of failure to notify the physician or responsible party, but not as a facility wide issue. He stated the facility reviewed clinical records every day when there was a reported or written documentation of a fall, change of condition, or resident need to ensure the process was completed correctly. The Administrator further stated he was responsible for the facility and the care the residents received while under the facility's care.

Based on observation, interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to develop a care plan for two (2) of sixteen (16) sampled residents, Residents #5 and #47. Resident #47 was diagnosed and treated for [REDACTED]. The resident was sent to the hospital on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In addition, the facility failed to develop a care plan for Resident #5's restraint. The findings included: Review of the facility's policy, Care Plans-Comprehensive, revised (MONTH) 2010, revealed areas of concern were to be added to the resident's care plan. Based on thorough assessment, the Minimum Data Set (MDS) team was to ensure the resident's focus, goals, and interventions were individualized for the resident with the needs. Identification and development of the care plan was obtained from consideration of the resident's identified problems and conditions. The facility was to have interventions, which addressed the underlying source of the problem, and to focus the intervention on the symptoms or triggers. The Interdisciplinary Team (IDT) was to re-evaluate the resident's care plan after re-admission to ensure new [DIAGNOSES REDACTED]. Review of the facility's policy, Goals and Objectives, Care Plans, revised (MONTH) 2011, revealed care plans were to include goals and objectives, and were to define desired outcomes for resident problems. Care plan goals and interventions were identified so facility staff were able to have access to the information and were able to report if the desired outcomes were not achieved. The facility goals and interventions were revised after the initial care plan when desired outcomes were not achieved. Review of the facility's policy, Using the Care Plan, revised (MONTH) 2006, revealed the resident care plans were used to assess, care, and re-evaluate the resident care needs. 1. Review of Resident #47's clinical record revealed the resident was diagnosed with [REDACTED]. On 11/26/18, the facility transferred the resident to the hospital after a fall and the facility readmitted the resident on 11/30/18, with [DIAGNOSES REDACTED]. Review of Resident #47's Significant Change MDS, dated [DATE], revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident #47's Nurses' Notes, dated 11/17/18 at 5:42 AM, revealed the resident complained of bladder pain and held his/her area of the lower abdomen. However, review of Resident #47's care plan revealed no evidence the facility developed a care plan with identified concerns, problems or conditions related to the resident's bladder pain. Review of Urinalysis Results, dated 11/22/18 at 9:16 PM, revealed Resident #47 had cloudy urine; specific gravity was marked abnormal with 1.010, abnormal presence of blood and abnormal protein presence in the urine. There was abnormal presence of Leukocytes (cells present with infections), abnormal Urine Red Blood Cells (URBC) and Urine White Blood Cells (UWBC), and abnormal high presence of bacteria in the urine. The facility faxed the results to the provider on 11/22/18, as noted on the lab result page. However, with this knowledge the facility did not develop a plan of care for Resident #47, related to the identified UTI. Further review of Resident #47's nursing documentation, revealed on 11/23/18 at 1:22 AM, staff reported Resident #47 was unable to walk from the bathroom and the resident stated he/she was hot, was cold, and very sick. Nursing staff assessed the resident to have a temperature of 102.6 with a pulse rate of 123 beats per minute. The resident also had dry heaves. The facility notified the physician of Resident #47's condition, as well of the lab results at this time. Licensed Practical Nurse (LPN) #7 noted the physician ordered antibiotics and if there was no change in status to send to the emergency room (ER) for evaluation and treatment. However, the facility did not develop a plan of care after receiving orders and direction from the physician regarding Resident #47's identified UTI. Review of Resident #47's Urine Culture, dated 11/25/19 at 8:03 AM, revealed Escherichia Coli (E Coli - bacteria found in the intestines) was found in the urine when cultured. After the facility obtained the urine culture test results, continued record review revealed the facility did not develop a plan of care that directed staff in the care of the resident with a UTI. Review of Nurses' Notes, dated 11/26/18 at 1:30 AM, revealed Resident #47 was found on the floor and on his/her back and stated to LPN #7 he/she was engaged in a conversation with someone in the room, became distracted, and fell . The resident was assessed and had a skin tear to the back of the right arm. The physician was notified with orders received for a mobile x-ray. The resident was reeducated to use the call light and not to get up without assistance and staff provided additional fall mats to the bedside. At 5:34 AM, LPN #7 sent the resident to the ER related to the resident's complaint of increased hip pain. Interview with LPN #3, on 03/29/19 at 10:04 AM, revealed staff utilized care plans in order to care for residents correctly. She stated care plans were to be up to date, and should reflect a resident's condition and needs. She stated the nurse administration and MDS team reviewed the care plans. The LPN further stated the care plan was be accurate within at least a week of a resident's re-admission. Interview with the Unit Manager, on 03/29/19 at 10:24 AM, revealed the MDS team developed care plans and updated them quarterly, with change of condition, and as needed. She stated care plans for UTIs, were generated and placed on the care plan, when UTIs were chronic. The Unit Manager stated she did not randomly review care plans, but MDS completed a review during care plan meetings. Interview with the Director of Nursing (DON), on 03/29/19 at 2:46 PM, revealed care plans were reviewed when a significant change occurred, with a new [DIAGNOSES REDACTED]. She stated after a care plan meeting, the resident's care plan was reviewed. She stated Resident #47's UTI was not a chronic condition so therefore, was not identified as a problem. She stated it was everyone's responsibly to ensure resident care plans were accurate and reflected resident needs, which included active and potential issues. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed the facility reviewed resident care plans during the IDT morning meetings for admissions, readmission, and changes in conditions. He stated the resident care plan would be reviewed by MDS in the IDT meetings and new interventions or problems were added to the care plans. He stated the resident care plans were updated on a constant basis. He further stated the care plan process and reviews were discussed in the Quality Assurance and Performance Improvement (QAPI) meetings and issues were not identified. 2. Review of the CMS RAI User's Manual, dated 10/01/18, Chapter 3, Section P: Restraints and Alarms, revealed the definition of a restraint was any manual, physical, or mechanical device adjacent to the resident's body which the resident could not remove easily, and restricted freedom of movement or normal access to their body. Further review revealed when the facility used a restraint, care plans were to focus on the prevention of adverse effects of the physical restraint. Review of the facility's policy, Restraints, dated 07/01/12, revealed it was the facility's belief residents had the right to be free from physical restraints. However, if a resident developed medical symptoms that placed the resident at risk of harm to self or others, and restraint alternatives had been unsuccessful, the resident's physician and staff would assess whether a restraint would be helpful and the physician would order the least restrictive restraint. The policy further stated the restraint would be discontinued as soon as the resident's condition no longer required the intervention. Review of Resident #5's clinical record revealed the facility admitted the resident on 08/16/18, with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident was not interviewable. The facility determined the resident received extensive assistance of two (2) for transfers, walking, toileting, and personal hygiene. The facility used a chair alarm and a wander/elopement alarm on the resident daily. Review of an Occupational Therapy Order, dated 12/13/18, revealed the resident was provided a full lap tray for the wheelchair. Review of Resident #5's Physician Orders, dated 01/06/19, revealed the facility was to provide the resident with a full lap tray for the resident's wheelchair per Occupational Therapy. Review of the facility's Safety Device Assessment, dated 12/17/18, revealed Resident #5 was assessed related to use of a full lap tray when up in the wheelchair, and the facility determined the device restricted the resident's access to his/her body, and restricted the resident's freedom of movement. In addition, the facility determined the resident was cognitively aware of the device, able to remove it on command, and determined the device was not a restraint. However, observations of Resident #5, on 03/26/19 at 3:36 PM, 03/28/19 at 1:32 PM, and 03/29/19 at 9:19 AM, revealed the resident in a wheelchair with a full lap tray in front of the resident, attached to the wheelchair. The resident attempted to remove the lap tray on command and was physically unable to, and did not demonstrate understanding of the way the lap tray attached to the wheelchair. Observation, on 03/28/19 at 4:07 PM, revealed Registered Nurse (RN) #3 was speaking to Resident #5 in the resident's room. The resident was sitting in his/her wheelchair with the lap tray in front of him/her and the RN asked the resident to remove the lap tray. The resident pushed on the lap tray but was unable to remove it from the wheelchair. Review of Resident #5's Care Plan, dated 06/25/18, revealed the resident was at risk for injury related to falls with an intervention for a full lap tray, which was undated. However, a restraint care plan was not developed related to the resident's inability to remove the lap tray from his/her wheelchair. Interview, on 03/28/19 at 4:08 PM, with RN #3 revealed there was no order for checking Resident #5's lap tray every shift to ensure it was safe and was not restricting the resident's movement. The RN further stated the facility intended to be a restraint free facility, and nursing administration was responsible for ensuring the devices the facility used on residents were not restraints. According to the RN, when she asked Resident #5 to remove the lap tray from the wheelchair, the resident was not able to remove the tray on command. The RN stated the resident understood what the RN was asking him/her to do, tried to move the lap tray, but was unable to remove it successfully. Per interview, in the past she had seen Resident #5 shake the tray but had not seen him/her remove the tray, and she further stated, by definition the full lap tray was a restraint because the resident was unable to remove it. Observation, on 03/29/19 at 10:55 AM, revealed Resident #5 in the therapy room and Occupational Therapist (OT) #1 placed a full lap tray on the resident's wheelchair and asked the resident to remove it. When the resident did not attempt to follow the OT's request, the OT instructed the resident to place his/her hands on tray and push. The resident demonstrated he/she had difficulty understanding the OT's request, and was physically unable to remove the lap tray from the wheelchair. Interview with OT #1, on 03/29/19 at 10:59 AM, revealed the facility placed a full lap tray on Resident #5's wheelchair after the resident fell out of the chair and other interventions had been ineffective. She stated the therapy department did not assess devices, including lab trays, for whether or not they were restraints, and it was the responsibility of the nursing department to complete restraint assessments and develop care plans for a device such as a full lap tray. The OT revealed the resident was not able to take the lap tray off the wheelchair, and the lap tray restricted the resident's access to his/her lower extremities. Interview, on 03/28/19 at 4:57 PM and 3/29/19 at 2:40 PM, with the MDS Coordinator revealed she collected information about restraints and used the information when completing the MDS assessments. However, she stated she did not recall receiving information a full lap tray was placed on Resident #5's wheelchair. She stated without the information, she would not have known to list the item under restraints on the upcoming MDS unless she noticed it on the resident and questioned nursing administration about the device. The MDS coordinator reviewed the Safety Device assessment dated [DATE], and stated the facility determined the full lap tray restricted the resident's access to his/her body and therefore, the lap tray was a restraint. The MDS Coordinator stated the facility should have initiated a restraint care plan with interventions including monitoring the resident for safety and increased agitation. The Coordinator revealed Resident #5 used to have a half lap tray, which he/she was able to remove, and it was on the care plan as a previous intervention which was changed to the full lap tray, which was not acceptable. Interview, on 03/29/19 at 4:18 PM, with the DON revealed when lap trays were put in place, ideally, residents should be able to remove them on command. She stated the facility used the Safety Device assessment to determine if a device, such as a lap tray was a restraint. A restraint was a device that the resident was not able to access their body or not able to remove the device. The DON reviewed the Safety Device assessment, dated 12/17/18, which noted the device restricted Resident #5's access his/her body and the DON validated the device was a restraint. She stated the facility should have developed a care plan for Resident #5's restraint for safety, which included checking the device and maintaining the resident's dignity while the restraint was in use. In addition, she stated the care plan should have included continued evaluation for least restrictive devices, and potential elimination of the device. Interview, on 03/29/19 at 5:22 PM, with the Administrator revealed the facility's goal was to have no restraints in the facility; however, he was aware there were some in use. He stated the Interdisciplinary Team was to determine if a device was a restraint and he was not aware of any devices the facility had not identified appropriately as restraints. In addition, he stated the facility should identify when a device became a restraint by observing residents using the devices. The Administrator further stated he relied on nursing staff to complete assessments and the DON should have been doing audits of restraints. In addition, he stated the facility was to develop care plans for restraints.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was prepared in a safe and sanitary manner. Observation of the kitchen revealed surfaces and small appliances appeared dirty, and there were unlabeled and outdated foods in the refrigerator. In addition, staff failed to utilize proper hand hygiene during meal plating and staff failed to calibrate the food thermometer prior to testing the temperature of the food. The findings include: Review of the facility's policy, Food Storage and Retention, FDA Food Code (YEAR), undated, revealed ready to eat cereal could be stored for two (2) to three (3) months (opened), and ready to eat/prepared foods (leftovers, deli salads) up to seven (7) days. Review of the facility's policy, Handwashing, revised (MONTH) (YEAR), revealed handwashing was to be completed with employees associated with handling food. Hands were to be washed at the kitchen hand sink station and use a seperate dry paper towel to turn off the faucet to avoid contact with the faucet germs. Review of the facility's policy, Environment, revised (MONTH) (YEAR), and revealed all preparation areas, food service areas, and dining areas were to be maintained in a clean and sanitary condition. Review of the facility's policy, Thermometer Use, not dated, revealed thermometers were to be calibrated weekly. Observation of the kitchen, on 03/25/19 at 6:00 PM, revealed refrigerator #2 contained a container of yogurt, labeled as opened on 03/19/19, and a container of pimento cheese labeled as opened on 03/19/19 with a used by date of 03/22/19. In addition, the refrigerator contained two (2) unlabeled bologna sandwiches, two (2) opened/unlabeled hot dog packages, and two (2) unlabeled containers of dry cereal. Continued observations in the kitchen revealed multiple surfaces with copious amounts of food residue/crumbs, which included shelving, utensil drawer, a cart with dessert bowls, and a toaster. A greasy substance and food particles coated the dish warmer. Observation of the kitchen during lunch, on 03/27/19 at 10:56 AM, revealed the Dietary Manager (DM) washed his hands and turned off the faucet with a wet towel. In addition, the Day Cook failed to calibrate the thermometer prior to measuring food temperatures. Observation of the Day Cook and the Dietary Aide, on 03/27/19 at 11:12 AM, revealed they washed their hands, used a paper towel to dry their hands, and used the same towel to turn the faucet off. Continued observation of the tray line for the lunch meal, on 03/27/19 at 11:14 AM, revealed three (3) bowls with food residue on the inside of the bowls. These bowls were in a supply of bowls, available and ready to use during plating of the lunch meal. Observation, on 03/27/19 at 11:15 AM, revealed the DM washed his hands and used the same towel to both dry his hands and turn off the faucet. Interview with the Night Cook, on 03/25/19 at 6:30 PM, revealed he labeled containers when opened for (7) days, and labeled leftovers for seven (7) days. He stated all items should be individualized and labeled. The Night Cook stated food older than the seven (7) days could cause illness to the residents. In addition, the Night Cook stated he was not sure about the kitchen cleaning schedule. Interview with the Day Cook, on 03/27/19 at 11:01 AM, revealed she did not calibrate the thermometer and was never educated on calibration of the thermometer. Continued interview with Day cook, on 03/27/19 at 11:26 AM, revealed the hand hygiene process included using soap and water, rub hands together, between fingers, then rinse hands and dry hands. A new towel was to be used to turn off the faucet; however, she stated she did not use a new towel and did not receive training by the facility to use a new dry towel. She added she was unsure why staff should use a new dry towel, maybe because of germs. The Day Cook stated the dirty bowls were over looked after being ran through the dishwasher. Interview with the Dietary Aide, on 03/27/19 at 11:30 AM, revealed after washing hands, staff was to obtain a towel, dry their hands, and obtain a separate towel to turn off the faucet to help keep infections and bacteria from spreading. In addition, the Dietary Aide stated using a soiled or damp towel might contain undesirable contaminants that could make a resident ill. The Dietary Aide stated the DM provided training on hand washing. Interview with the DM, on 03/27/19 at 11:07 AM, revealed staff should calibrate the thermometer and confirmed they failed to do so during the observation. In addition, the DM stated he did not have documentation of thermometer calibration. He stated the purpose of calibrating the thermometer ensured the thermometer gave correct readings. The DM stated he trained new staff but did not train new staff on thermometer calibration. Continued interview at 11:42 AM, revealed he provided education on hand washing upon hire, which included drying hands with dry paper towel and using a clean dry paper towel to turn the faucet off. The DM stated he completed informal hand hygiene audits but did not document them; he just rounded and made observations of kitchen staff. He revealed dishes sometimes must be soaked to remove excess food prior to running them through the dishwasher. The DM stated improper hand hygiene and soiled plates and utensils might cause a resident to get sick and spread infection. Interview with the Administrator, on 03/27/19 at 3:10 PM, revealed he was not aware of concerns, nor had the Quality Improvement Committee identified any concerns, related to kitchen staff and hand hygiene, labeling of food products, or general cleanliness of the kitchen.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store controlled medication in a permanently affixed, locked compartment in one (1) of two (2) medication rooms, on the West Wing. Observation revealed controlled medication stored in the refrigerator; however, it was not in a permanently affixed compartment. In addition, observations revealed two (2) of two (2) unlocked medication carts not under supervision of staff. The findings include: 1. Review of the facility's policy, Storage of Medications, revised (MONTH) 2007, revealed medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station, or other secured location. Medications must be stored separately from food and must be labeled accordingly. The policy did not address controlled medications stored within a locked, permanently affixed box within the refrigerator. Observation of the West Wing Medication Room, on 03/28/19 at 10:24 AM, revealed the refrigerator contained a small white plastic basket with bags of controlled medication. The basket was not locked, nor affixed to any surface in the refrigerator. The basket contained twenty-three (23) [MEDICATION NAME] 2.5 milligram (mg) tablets; two (2) unopened [MEDICATION NAME] 2 gram (gm) vials; and eight (8) unopened [MEDICATION NAME] 2 mg vials. Interview with the Unit Manager (UM), on 03/28/19 at 11:05 AM, revealed she was not aware the controlled medication needed to be in a permanently affixed, locked box in the refrigerator, because medications were in a locked medication room, and locked refrigerator. The UM further revealed there was a potential for someone with a key to the medication room and controlled substance refrigerator to walk out with the medication because it was not in an attached container, and instead sat in a plastic basket loose in the refrigerator. Interview with Assistant Director of Nursing (ADON), on 03/29/19 at 1:26 PM, revealed refrigerated controlled medication was behind two (2) locks, one to get into the medication room and the other to get into the refrigerator. The ADON further revealed the refrigerated controlled mediations were loose in a white plastic basket, not affixed to the refrigerator. She stated if controlled medications were kept in a locked compartment, permanently affixed to the refrigerator, it could help prevent diversion. Interview with Director of Nursing (DON), on 03/29/19 at 2:51 PM, revealed the facility had never had a permanently affixed lock container for refrigerated controlled medication in the medication room. The DON further revealed loose controlled medication in the refrigerator made it possible for someone to easily divert the medication, and if the controlled medication were diverted, residents would not have their medication. 2. Review of the facility's policy, Security of the Medication Cart, revised (MONTH) 2007, revealed the nurse was to secure the medication cart to prevent unauthorized entry. All carts were to be locked before staff entered a resident's room and at all times when out of the assigned nurse's view. Further review revealed when the cart was not utilized it was to be parked and locked at all times. Observation, on 03/25/19 at 6:23 PM, revealed a medication cart located in the activity room was unlocked and unattended by nursing staff. The activity area had multiple residents who were walking up to and or past the cart. Continued observation revealed on the East Wing Hall, a medication cart was unlocked and out of staff's view, as two (2) residents walked past the cart. Observation, on 03/26/19 at 11:30 AM, revealed LPN #3 was in Resident #33's room and positioned the unlocked medication cart in front of the opened resident's door within view. However, LPN #3 closed the door to assist with care and the door remained closed for ten (10) minutes. Residents, staff, and visitors walked past the medication cart. Interview with LPN #3, on 03/26/19 at 12:37 PM, revealed medication carts were to be locked at all times. She stated with the door closed, the unlocked medication cart was not within her view, which meant the cart became unsafe. She stated she received training on medication cart safety that included locked medication carts. She stated residents were at risk for reactions and harm if they accessed and ingested medications that were not prescribed to them. She further stated the facility previously identified issues with unlocked medication carts. Interview with the DON, on 03/26/19 at 12:45 PM, revealed medication carts were to be attended or locked at all times. She stated staff was able to have unlocked medication carts at resident doors if the carts faced the room and were within eyesight at all times. She stated she audited the facility for unlocked medication carts when she was on the units and had not identified issues with unlocked carts. Per the DON, the facility previously identified medication cart safety issues concerning medication carts not monitored by staff. She further stated residents who accessed medications not prescribed to them were at risk to get sick or worse and the facility had many residents with cognition issues who wandered. Continued interview with the DON, on 03/29/19 at 2:46 PM, revealed she felt the staff became complacent with ensuring medication carts were locked. Interview with the Administrator, on 03/29/19 at 3:10 PM, revealed previous issues with medication cart securement was identified by the facility. The DON conducted in-services that staff was mandated to attend, audits were completed, and no further issues were identified.

Based on observation, interview, facility policy review, and review of the Plan of Correction (P[NAME]) for the 03/29/19 Recertification Survey, it was determined the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program to ensure compliance was maintained regarding medication cart security. Observations revealed two (2) of four (4) medication carts were unlocked and unattended by staff. (Refer to F761) The findings include: Review of the facility's policy, Quality Review and QAPI Plan Standard Practice, revised (MONTH) 17, revealed the goal of the facility was not to have repeated citations of a D level or higher in a fifteen (15) month time period. The committee was to monitor the compliance with the P[NAME]. Under the direction of the Administrator, the facility was to verify the action plan and Performance Improvement Plan (PIP) were in place. The QA committee was to monitor the facility's compliance with the P[NAME]. Review of the P[NAME] for the survey conducted 03/29/19, revealed the Director of Nursing (DON) completed a facility audit for unlocked medication carts on 04/20/19, which revealed no concerns. Education was conducted by the Chief Nursing Officer and/or the DON for all licensed nursing staff and the Kentucky Medication Aides (KMA) and included the importance and responsibility of a maintained locked medication cart when not supervised. Furthermore, the DON, Assistant Director of Nursing (ADON), and or Unit Manager (UM) were to complete medication carts audits weekly for four (4) weeks and then monthly for two (2) months to ensure medication carts were locked. Observation, on 05/21/19 at 12:07 PM, revealed an unlocked medication cart that was unattended by nursing staff on the West Hall. At 12:10 PM, Licensed Practical Nurse (LPN) #3 entered the hallway, removed supplies from the cart without the use of the cart keys, and proceeded to lock the cart. Interview with LPN #3, on 05/21/19 at 2:21 PM, revealed she had left the medication cart on the West Hall unlocked, unsupervised and was on the other hall of the facility during the time of the observation. She further stated nursing administration had found her cart previously unlocked and had not provided re-education or in-services after the cart was found unlocked. Observation, on 05/21/19 at 1:57 PM, revealed there was an unlocked and unattended medication cart on the East Hall with staff and residents ambulating by the cart. At 2:00 PM, the ADON locked the cart as she passed the cart on the way out of the facility. LPN #6 stepped out of a room two (2) doors down from the medication cart and returned the cart. Interview with the ADON, on 05/21/19 at 2:10 PM, revealed she identified the medication cart on the East Hall was unlocked and locked the cart as she passed by. She stated she was unsure which room the nurse was in so she did not address the unlocked cart immediately. According to the ADON, facility audits had not identified issues with unlocked medication carts. Review of the Daily Clinical Meeting Follow-up Tool, date 05/14/19 through 05/24/19, revealed the facility did not identify concerns for follow-up. Interview with the Medical Director, on 05/24/19 at 10:20 AM, revealed the facility completed an ad-hoc QAPI review of the survey results, which included F761. He stated the facility developed a plan with audits, which were ongoing. He further stated he was not informed of any issues with ongoing audits of medication carts. Interview with the UM, on 05/24/19 at 10:38 AM, revealed QAPI met after the survey and came up with the plan for medication cart safety. She stated staff was audited all day long when she walked the units as she always observed for open carts and had not identified issues with carts unlocked. The UM stated the DON audited medication carts once a week. She stated the facility conducted the monthly QAPI for (MONTH) 2019 without identified issues reported in the meeting. Continued interview with the ADON, on 05/24/19 at 11:21 AM, revealed the QAPI team met and reviewed the survey findings and the nursing department re-educated staff on medication cart safety. She stated she and the DON completed walking rounds multiple times a day to observe medication carts on all shifts. According to the ADON, with the exception of the medication carts found unlocked on 05/21/19, she and the DON were not aware of medication carts unlocked and unattended by staff. Interview with the DON, on 05/24/19 at 10:21 AM, revealed after the 03/29/19 survey, the QAPI committee met to review the citations and put forth a P[NAME] for medication cart safety. She stated staff was educated and monitoring was conducted, she completed cart audits weekly, and the nursing administration staff were monitoring whenever they were out on the floor. Neither the DON nor other administrative nursing staff identified nurses leaving the carts unlocked and unattended. She stated it was reported to QAPI that medication cart audits revealed staff was compliant with locking the carts. Interview with the Administrator, on 05/22/19 at 1:23 PM, revealed the facility held an ad-hoc meeting immediately after the 03/29/19 survey and the QAPI committee reviewed the findings and discussed the needs to address the citations. The Administrator further stated the QAPI committee agreed to educate staff on safety in regards to medication cart securement and the DON and nursing administration team had not reported negative findings. He further stated he needed to be stricter with the audits because staff had not complied with the P[NAME] interventions.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free from unnecessary restraints for one (1) of four (4) sampled residents, Residents #5. The findings include: Review of the facility's policy, Restraints, dated 07/01/12, revealed it was the facility's belief residents had the right to be free from physical restraints. However if a resident developed medical symptoms which placed the resident at risk of harm to self or others and restraint alternatives had been unsuccessful, the resident's physician and staff would assess whether a restraint would be helpful and the physician would order the least restrictive restraint. The policy further stated the restraint would be discontinued as soon as the resident's condition no longer required the intervention. Review of Resident #5's clinical record revealed the facility admitted the resident on 08/16/18, with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident was not interviewable. The facility determined the resident received extensive assistance of two (2) staff for transfers, walking, toileting, and personal hygiene. The facility used a chair alarm and a wander/elopement alarm on the resident daily. Review of an Occupational Therapy (OT) Order, dated 12/13/18, revealed Resident #5 was provided a full lap tray for the wheelchair. Review of Resident #5's Physician order [REDACTED]. The order did not include information on continued assessment of the device for restraint, frequency of use, or frequency staff was to release the tray and assist the resident with repositioning. Review of Resident #5's Safety Device Assessment, dated 12/17/18, revealed the resident was assessed related to use of a full lap tray when up in wheelchair, and the facility determined the device restricted the resident's access to his/her body, and restricted the resident's freedom of movement. However, the facility determined the device was not a restraint. There were no other Safety Device Assessments conducted after 12/17/18. Observations, on 03/26/19 at 3:36 PM, 03/28/19 at 1:32 PM, and 03/29/19 at 9:19 AM, revealed Resident #5 in a wheelchair with a full lap tray in front of the resident and attached to the wheelchair. The resident attempted to remove the lap tray on command, was physically unable to, and did not demonstrate understanding of the way the full lap tray was attached to the wheelchair. Observation of Resident #5, on 03/28/19 at 4:07 PM, revealed Registered Nurse (RN) #3 was with the resident in his/her room and asked the resident to remove the lap tray from the wheelchair. The resident pushed on the lap tray but was unable to remove it from the wheelchair. Review of Resident #5's Care Plan revealed the facility had not identified the lap tray as a restraint, as there was no plan for restraint use. Interview with RN #3, on 03/28/19 at 4:08 PM, revealed the facility should have clarified the order for the full lap tray for Resident #5 to include the purpose or function of the tray. In addition, there was no order for checking the tray every shift to ensure it was safe and that it was not restricting movement. The RN further stated the facility intended to be a restraint free facility, and nursing administration was responsible for ensuring devices used on residents were not restraints. The nurse revealed when she asked Resident #5 to remove the full lap tray from the wheelchair, the resident was not able to remove the tray on command. The resident understood what she was asking him/her to do and tried to move the lap tray, but was unable to remove it successfully. The RN stated the resident became tearful and agitated during his/her attempt to remove the lap tray. She further stated she had seen Resident #5 shake the lap tray in the past, but had not seen him/her remove the tray. The RN further stated by definition, the full lap tray was a restraint because the resident was unable to remove the tray on command. She continued to state risks of restraint use on residents included impaired skin integrity, development of contractures due loss of movement, and loss of independence. Observation of Resident #5, on 03/29/19 at 10:55 AM, revealed the resident was in the therapy room and OT #1 placed a full lap tray on the resident's wheelchair and asked the resident to remove it. When the resident did not attempt to follow the OT's request, the OT instructed the resident to place his/her hands on tray and push. The resident asked the OT, Do you mean push you? The resident demonstrated he/she had difficulty understanding the OT's request and was physically unable to remove the full lap tray from the wheelchair he/she was sitting in. Interview with OT #1, on 03/29/19 at 10:59 AM, revealed she placed a full lap tray on Resident #5's wheelchair after the resident had leaned too far forward while sitting in the wheelchair and fell out, because other interventions had been ineffective. The OT further stated staff should place the lap tray on the resident's wheelchair when the resident was out of bed, and should remove the tray when the resident participated in restorative services or activities with supervision. She revealed when devices, such as the full lap tray, were put in place, the therapy department observed resident's behavior while in the wheelchair and assessed the resident for improvement in posture, safety, and ability to engage in activities with other residents. Per interview, the therapy department did not assess devices, including lap trays, for whether or not they were restraints, and it was the responsibility of the nursing department to complete restraint assessments. The OT stated since the resident was not able to remove the lap tray, the tray restricted the resident's access to his/her lower extremities. There was a risk the resident could scoot down under the tray and hurt himself/herself. She stated the order for the lap tray should have included the purpose of the tray, such as to promote safety, improve mobility, and for posture. According to OT #1, the facility did not provide training related to restraints and she had not read a facility policy regarding restraints. Interview with the MDS Coordinator, on 03/28/19 at 4:57 PM and 3/29/19 at 2:40 PM, revealed she reviewed the Safety Device Assessment, dated 12/17/18, and stated the facility determined the full lap tray restricted the resident's access to his/her body and therefore, the lap tray was a restraint. The Coordinator stated there was a risk the lap tray could result in contractures, limited mobility, and psychosocial problems related to limiting mobility and social interaction. Interview with Activities Assistant #1, on 03/29/19 at 3:36 PM, revealed she had received training about restraints when trained to be a Certified Nursing Assistant (CNA). She stated if a resident was not able to remove a lap tray from their wheelchair, then the tray was a restraint. She further stated Resident #5 was not able to remove the tray from his/her wheelchair. The Activities Assistant stated the risk for the resident was the resident could lose range of motion. Interview with the Director of Nursing (DON), on 03/29/19 at 4:18 PM, revealed when the facility placed lap trays on residents' wheelchairs, ideally the residents should be able to remove them on command. She stated the facility used the Safety Device Assessment to determine if a device, such as a lap tray, was a restraint and if staff determined the resident was not able to access their body, or not able to remove the device, then the device was a restraint. The DON reviewed Resident #5's Safety Device Assessment, dated 12/17/19, which noted the device restricted Resident #5's access his/her body and the DON validated the device was a restraint. The DON stated risks of using restraints on residents were the resident could become withdrawn, their appetite could be negatively affected, and the resident could develop skin issues. She stated the facility did not do any audits of restraints, and did not do any audits of devices, which could become restraints. Interview with the Administrator, on 03/29/19 at 5:22 PM, revealed the facility's goal was to have no restraints; however, he was aware there were some in use. He stated it was the responsibility of the Interdisciplinary Team to determine if a device was a restraint, and he was not aware of any devices the facility had not identified as restraints. In addition, he stated the facility should identify when a device became a restraint by observing residents and nursing staff completing assessments. According to the Administrator, the DON should be doing audits of restraints.

Based on observation, interview, facility policy review, and review of the Plan of Correction (P[NAME]) for the 03/29/19 Recertification Survey, it was determined the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program to ensure compliance was maintained regarding medication cart security. Observations revealed two (2) of four (4) medication carts were unlocked and unattended by staff. (Refer to F761) The findings include: Review of the facility's policy, Quality Review and QAPI Plan Standard Practice, revised (MONTH) 17, revealed the goal of the facility was not to have repeated citations of a D level or higher in a fifteen (15) month time period. The committee was to monitor the compliance with the P[NAME]. Under the direction of the Administrator, the facility was to verify the action plan and Performance Improvement Plan (PIP) were in place. The QA committee was to monitor the facility's compliance with the P[NAME]. Review of the P[NAME] for the survey conducted 03/29/19, revealed the Director of Nursing (DON) completed a facility audit for unlocked medication carts on 04/20/19, which revealed no concerns. Education was conducted by the Chief Nursing Officer and/or the DON for all licensed nursing staff and the Kentucky Medication Aides (KMA) and included the importance and responsibility of a maintained locked medication cart when not supervised. Furthermore, the DON, Assistant Director of Nursing (ADON), and or Unit Manager (UM) were to complete medication carts audits weekly for four (4) weeks and then monthly for two (2) months to ensure medication carts were locked. Observation, on 05/21/19 at 12:07 PM, revealed an unlocked medication cart that was unattended by nursing staff on the West Hall. At 12:10 PM, Licensed Practical Nurse (LPN) #3 entered the hallway, removed supplies from the cart without the use of the cart keys, and proceeded to lock the cart. Interview with LPN #3, on 05/21/19 at 2:21 PM, revealed she had left the medication cart on the West Hall unlocked, unsupervised and was on the other hall of the facility during the time of the observation. She further stated nursing administration had found her cart previously unlocked and had not provided re-education or in-services after the cart was found unlocked. Observation, on 05/21/19 at 1:57 PM, revealed there was an unlocked and unattended medication cart on the East Hall with staff and residents ambulating by the cart. At 2:00 PM, the ADON locked the cart as she passed the cart on the way out of the facility. LPN #6 stepped out of a room two (2) doors down from the medication cart and returned the cart. Interview with the ADON, on 05/21/19 at 2:10 PM, revealed she identified the medication cart on the East Hall was unlocked and locked the cart as she passed by. She stated she was unsure which room the nurse was in so she did not address the unlocked cart immediately. According to the ADON, facility audits had not identified issues with unlocked medication carts. Review of the Daily Clinical Meeting Follow-up Tool, date 05/14/19 through 05/24/19, revealed the facility did not identify concerns for follow-up. Interview with the Medical Director, on 05/24/19 at 10:20 AM, revealed the facility completed an ad-hoc QAPI review of the survey results, which included F761. He stated the facility developed a plan with audits, which were ongoing. He further stated he was not informed of any issues with ongoing audits of medication carts. Interview with the UM, on 05/24/19 at 10:38 AM, revealed QAPI met after the survey and came up with the plan for medication cart safety. She stated staff was audited all day long when she walked the units as she always observed for open carts and had not identified issues with carts unlocked. The UM stated the DON audited medication carts once a week. She stated the facility conducted the monthly QAPI for (MONTH) 2019 without identified issues reported in the meeting. Continued interview with the ADON, on 05/24/19 at 11:21 AM, revealed the QAPI team met and reviewed the survey findings and the nursing department re-educated staff on medication cart safety. She stated she and the DON completed walking rounds multiple times a day to observe medication carts on all shifts. According to the ADON, with the exception of the medication carts found unlocked on 05/21/19, she and the DON were not aware of medication carts unlocked and unattended by staff. Interview with the DON, on 05/24/19 at 10:21 AM, revealed after the 03/29/19 survey, the QAPI committee met to review the citations and put forth a P[NAME] for medication cart safety. She stated staff was educated and monitoring was conducted, she completed cart audits weekly, and the nursing administration staff were monitoring whenever they were out on the floor. Neither the DON nor other administrative nursing staff identified nurses leaving the carts unlocked and unattended. She stated it was reported to QAPI that medication cart audits revealed staff was compliant with locking the carts. Interview with the Administrator, on 05/22/19 at 1:23 PM, revealed the facility held an ad-hoc meeting immediately after the 03/29/19 survey and the QAPI committee reviewed the findings and discussed the needs to address the citations. The Administrator further stated the QAPI committee agreed to educate staff on safety in regards to medication cart securement and the DON and nursing administration team had not reported negative findings. He further stated he needed to be stricter with the audits because staff had not complied with the P[NAME] interventions.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received adequate supervision to prevent an accident for one (1) of five (5) sampled residents, Resident #2. A Certified Nursing Assistant (CNA) transferred Resident #2 using a mechanical lift without the assistance of another staff member and the resident sustained [REDACTED]. The facility assessed Resident #2 was at risk for falls and required two (2) staff to transfer with use of a mechanical lift; however, on 06/28/18, CNA #3 attempted to transfer Resident #2 using a mechanical lift without the assistance of a second staff member. Per interview, the resident slid out of the sling and fell to the floor when a loop came loose from the lift. The facility transferred the resident to the emergency room where he/she was diagnosed with [REDACTED]. The State Survey Agency determined the facility completed corrective action and achieved substantial compliance on 07/01/18, prior to the start of the investigation on 09/04/18; therefore, the deficient practice was determined to be past noncompliance. The findings include: Review of the facility's Incident and Accident Process, revised (MONTH) (YEAR), revealed the purpose of the process was to ensure the facility environment was free from accident hazards over which the facility had control, and to ensure each resident received adequate supervision and assistive devices to prevent avoidable accidents. The facility did not provide a policy for Mechanical Lifts. Review of Mosby's Long Term Care Nursing Assistant Textbook, 7th Edition, revealed at least two (2) staff members were needed when using a mechanical lift. Review of Resident #2's clinical record revealed the facility admitted the resident on 09/11/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) and determined he/she was interviewable. Further review revealed the resident required the assistance of two (2) staff for transfers. Review of Physician Orders, dated (MONTH) (YEAR), revealed an order, dated 05/22/18, to use a sling lift for transfers to enable safe transfers related to weakness. Review of the Fall Risk Data Sheet, dated 02/19/18, revealed the facility assessed Resident #2 with a fall risk score of twelve (12) out of eighteen (18) and determined he/she was a high risk for falls. Review of Resident #2's Care Plan, dated 05/28/18, revealed he/she was at risk for injury related to decreased mobility and a goal for the resident not to fall or have a fall related injury, which included an intervention to transfer the resident with a mechanical lift with two (2) persons. Review of Resident #2's Nurses Notes, dated 06/28/18, revealed Registered Nurse (RN )#2 documented the CNA needed her for the resident and upon arrival to the resident's room, she observed the resident on the floor, face down. First-aid was administered. Continued review of Resident #2's Nurses Notes, dated 06/28/18, revealed the Assistant Director of Nursing (ADON) documented the resident was face down on the floor at 4:30 PM. An assessment was completed and the resident had a skin tear to the right forearm, knee, hand, and forehead. The resident denied pain. The physician and family were notified and the resident was sent to the hospital. Review of the hospital Emergency Physician Record, dated 06/28/18, revealed Resident #2 presented to the emergency room (ER) with a hematoma (collection of blood) to the right forehead, abrasion to the right knee, and a skin tear to the right arm. The ER physician diagnosed the resident with a concussion (without loss of consciousness) and discharged him/her back to the facility. Observation and interview, on 09/04/18 at 1:35 PM, revealed Resident #2 lying in bed with no concerns related to his/her care. Interview with CNA #3, on 09/05/18 at 9:35 AM, revealed she attempted to transfer Resident #2 alone using the mechanical lift on 06/28/18, because she was unable to locate another staff member to help. She stated when she pulled the lift away from the bed, the strap of the sling came off the hook, and the resident slid out of the sling to the floor. According to the CNA, the resident hit his/her forehead on the floor and his/her legs on the lift base. She stated she left the resident and immediately ran to find a nurse. CNA #3 stated RN #2 and other staff returned with her to the room, assessed the resident, and returned him/her to bed. CNA #3 revealed she could not find Resident #2's assigned nurse and did not know where the nurse was when the resident fell . Further interview with CNA #3 revealed the purpose of using two (2) staff with a mechanical lift was to verify correct attachment of the sling and guide the sling during the transfer. She stated it was important to follow procedure to ensure resident safety and prevent potential falls, injury, fractures, or death. Interview with CNA #8, on 09/04/18 at 3:00 PM, revealed staff should always wait for a second person to assist with a mechanical lift because a resident could fall out of the sling or the lift could turn over. Review of the Staffing Schedule, dated 06/28/18, revealed Licensed Practical Nurse (LPN) #1 was assigned to the East Hall and Resident #2. LPN #1 was also assigned to the Restorative dining room for supper. Interview with LPN #1, on 09/05/18 at 12:07 PM, revealed he was responsible for notifying the split hall nurse if he left the hall. He stated there should always be a nurse available on the hall in case a resident requested medication or there was an accident or emergency. Further interview on 09/06/18 at 11:31 AM, revealed he could not recall where he was when Resident #2 fell and stated he sometimes went outside to smoke before going to the Restorative dining room for supper. Interview with RN #2, on 09/05/18 at 11:45 AM, revealed she was assigned as the split nurse for East/West Hall on 06/28/18. She stated she was at the West Hall nurses' station when CNA #3 notified her of Resident #2's fall. The RN stated she went to the resident's room on the East Hall and assessed the resident, notified the physician, and transferred the resident to the ER per the physician's orders [REDACTED].>Further interview with RN #2 revealed a nurse should be on the hall at all times to monitor care and be available in the event of an emergency. She further revealed the assigned nurse was responsible for notifying another nurse and/or CNA if leaving the unit for an extended period of time, such as a lunch break. The RN stated she was not aware Resident 2's assigned nurse was outside smoking when the fall occurred. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed a CNA notified her of Resident #2's fall and she went to the resident's room and assisted RN #2 with transferring the resident back to bed. The ADON stated CNA #3 attempted to transfer the resident alone and did not follow the facility's mechanical lift procedure. Interview with the Director of Nursing (DON), on 09/05/18 at 3:13 PM, revealed the facility determined incorrect attachment of the sling to the lift resulted in Resident #2's fall. She further revealed CNA #3 should have had another person to assist her with the transfer; in addition, she had not identified any concerns with improper use of mechanical lifts prior to Resident #2's fall. Further interview with the DON revealed nurses were responsible for notifying another nurse and the assigned CNA when leaving the hall for breaks, lunch, or Restorative dining. Interview with the Administrator, on 09/06/18 at 12:50 PM, revealed CNA #3 did not follow the facility's policy and procedure for transfers with a mechanical lift. The Administrator stated he felt the incident involving Resident #2 was an isolated event. The facility implemented the following actions to correct the deficient practice: 1. The Medical Director was notified of the incident on 06/28/18. 2. The facility reassessed Resident #2's fall risk on 06/28/18 and reviewed the care guide and care plan to verify the correct transfer status. Notifications to family, physician, and Administrator were made according to policy. 3. The Unit Manager (UM) reviewed and verified sixty-three (63) resident care guides and care plans for correct transfer status on 06/30/18. 4. The facility re-educated all staff present in the building on 06/28/18 regarding proper Mechanical Lift Procedure. The UM and Assistant Director of Nursing (ADON) conducted the training. The education included a return demonstration using the manufacturer's Total Lift Procedure skills check off. Twenty-two (22) staff members were present and educated. The facility re-educated thirty-two (32) additional staff members regarding Mechanical Lift Procedure on 06/29/18, 06/30/18, 07/02/18, and 07/03/18 prior to the start of the staff members shift and prior to providing direct care. Completion of the training occurred on 07/03/18. 5. The facility implemented a Lift Binder, located on each nursing unit. Nursing staff would refer to the binder to ensure the correct lift and sling size was used to transfer a resident. The UM and ADON would review new physician orders [REDACTED]. 6. The Maintenance Director inspected two (2) of two (2) mechanical lifts in the building on 06/28/18 and completed an inspection of Resident #2's sling. The facility would conduct monthly inspections of the mechanical lifts and inspections of slings each time they were washed, and would be ongoing. 7. The UM, ADON, and Director of Nursing (DON) audited staff performing transfers using a mechanical lift to ensure the transfer was performed according to the facility procedure and the resident care guide. Audits started on 06/30/18 and were completed twice a shift for one (1) week, once a shift for one (1) week, and daily for one (1) week. The audits were completed on 07/20/18. 8. The Administrator conducted an emergency Ad Hoc QA Meeting with the care team on 06/28/18. The monthly QA was conducted on 07/02/18 and Fall Committee Meetings were held on 07/05/18 and 07/25/18 to review the progress and findings of the Action Plan. The State Survey Agency validated the facility implemented the following: 1. Interview with the Administrator, on 09/06/18 at 12:50 PM, revealed the Medical Director was on site at the time of the incident on 06/28/18 and participated in the Ad Hoc meeting. 2. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed she notified the Administrator of the incident and sent Certified Nursing Assistant (CNA) #3 home on 06/28/18. Review of the clinical record for Resident #2 revealed the care plan was reviewed and revised on 06/28/18. The Fall Care Plan reflected an intervention for transfers with a mechanical lift with two (2) persons. A Fall Investigation and Fall Risk Assessment were completed on 06/28/18. Further review revealed the family and physician were notified of the fall on 06/28/18. 3. Interview with the UM, on 09/05/18 at 4:15 PM, revealed she reviewed and verified the CNA care guides and care plans for sixty-three (63) residents to ensure the correct transfer requirements were in place. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed her and the UM verified all CNA care guides and resident care plans to ensure accuracy. Review of the clinical records for Resident #1, #2, #3, #4, and #5 revealed the care guides and care plans reflected the correct transfer status. 4. Interview with CNA #1, on 09/06/18 at 3:00 PM, revealed she was retrained on mechanical lifts. She stated the training covered how to attach the sling, color coding related to sling size, and weight limits of the slings. She stated a binder was located on each hall to refer to resident lift requirements. CNA #1 revealed mechanical lifts required two (2) persons at all times. Interview with Hospitality Aide #1, on 09/06/18 at 3:12 PM, revealed she was trained on the use of mechanical lifts. She stated two (2) people were required to perform mechanical lifts. Interview with Licensed Practical Nurse (LPN) #1, on 09/06/18 at 3:06 PM, revealed staff were re-trained on mechanical lifts on the evening of Resident #2's fall. The LPN stated staff was required to demonstrate the correct lift procedure for competency. He stated two (2) persons must be present at all times when performing a mechanical lift. Interview with Registered Nurse (RN) #1, on 09/06/18 at 3:03 PM, revealed the facility had conducted training on lifts within the last two (2) to three (3) months. She stated the training included correct use of the lift, safety hazards, and verification of the sling attachment. The RN stated two (2) persons were required at all times to perform lifts. Interview with LPN #2, on 09/04/18 at 2:40 PM, revealed two (2) persons were required at all times to perform mechanical lifts to ensure resident safety and prevent potential falls. The LPN revealed the facility retrained and conducted competency checks with all nursing staff on the correct use of mechanical lifts following Resident #2's fall. Interview with the UM, on 09/05/18 at 4:15 PM, revealed the facility removed the lift/sling from service immediately following the incident and retrained all staff on-site regarding the mechanical lift policy and procedure. The UM revealed all staff was required to complete the mandatory training prior to working their next scheduled shift. She revealed the facility implemented the use Lift Binders as a part of the Action Plan. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed an Action Plan was initiated on the evening of 06/28/18 and all nursing staff on-site was educated regarding transfer techniques and correct use of the lift. She stated all staff were educated prior to their next scheduled shift and were required to perform a return demonstration to determine competency. Record review revealed fifty-four (54) of fifty-four (54) staff was trained on proper Mechanical Lift Procedure by 07/03/18. 5. Interview with CNA #8, on 09/04/18 at 3:00 PM, revealed she referred to the Lift Binder to determine the transfer requirements for a resident. She stated the book was located at the CNA kiosk and contained the lift information and care needs of each resident. Interview with CNA #9, on 09/04/18 at 2:15 PM, revealed she used the Lift Binder to determine a resident's transfer status. She stated the Lift Binder indicated the type of lift and sling size to be used for any resident that required a mechanical lift. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed the facility implemented a binder for each hall to identify residents requiring a mechanical lift. Interview with the DON, on 09/05/18 at 3:13 PM, revealed the facility implemented Lift Binders that contained a list of residents who required mechanical lifts, a picture of each resident, the type of lift to be used, and the appropriate sling size. Review of the Lift Binder revealed Resident #2 was listed in the book and included his/her picture and lift requirements for two (2) person assist with mechanical lift and a green sling. The facility's lift procedure and a list of sling weight limits were also in the binder. 6. Interview with the Maintenance Director, on 09/04/18 at 4:25 PM, revealed he inspected the lift and sling involved in Resident #2's fall on 06/28/18 and found no defects. The Director stated he also inspected the West Hall lift on 06/28/18 and found no defects. He revealed mechanical lifts were inspected monthly and as needed to assess for wear and damage. Record review revealed the Maintenance Director inspected two (2) mechanical lifts on 06/28/18, including slings. 7. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed audits were conducted to monitor staff utilizing the mechanical lifts to ensure two (2) staff was present. Record review revealed audits of staff using mechanical lifts were conducted 06/30/18 to 07/20/18. 8. Interview with the UM, on 09/05/18 at 4:15 PM, revealed the facility held an emergency Ad Hoc Quality Assurance (QA) meeting with the Medical Director on the evening of the incident to review the findings of the investigation and discuss an Action Plan. Interview with the DON, on 09/05/18 at 3:13 PM, revealed the audit findings for lift transfers were reviewed during weekly and monthly QA meetings until the audits were completed on 07/20/18. She stated no further concerns were identified during the audits and the facility determined Resident #2's fall was an isolated incident. Interview with the Administrator, on 09/06/18 at 12:50 PM, revealed the facility held an Ad Hoc QA meeting on 06/28/18 to review Resident #2's fall, the investigation, and the Action Plan. The Administrator stated the Medical Director participated in the Ad Hoc meeting. The Administrator revealed there were no new issues identified as a result of the lift audits and he felt the incident involving Resident #2 was an isolated event. He stated the facility's date of compliance was 06/29/18, as all staff working on 06/28/18 was educated that day and no other staff was allowed to work until they received the education.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan to prevent a fall for one (1) of five (5) sampled residents, Resident #2. A Certified Nursing Assistant (CNA) transferred Resident #2 using a mechanical lift without the assistance of another staff member and the resident sustained [REDACTED]. Resident #2 had a care plan in place to prevent a fall with an intervention for staff to use a mechanical lift with two (2) persons when transferring the resident. On 06/28/18, a CNA failed to follow the care plan and attempted to transfer the resident using a mechanical lift without the assistance of a second staff member. Per staff interview, the resident slid out of the sling and fell to the floor when a loop came loose from the lift. The facility transferred the resident to the emergency room where he/she was diagnosed with [REDACTED]. The State Survey Agency determined the facility completed corrective action and achieved substantial compliance on 07/01/18, prior to the start of the investigation on 09/04/18; therefore, the deficient practice was determined to be past noncompliance. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, revised (MONTH) (YEAR), revealed it was the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and time frames that met the resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. The comprehensive care plan would describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the clinical record revealed the facility admitted Resident #2 on 09/11/13, with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident required the assistance of two (2) staff for transfers. Review of Resident #2's Fall Risk Data Sheet, dated 02/19/18, revealed the facility assessed the resident with a score of twelve (12) out of eighteen (18) and determined he/she was at high risk for falls. Review of Resident #2's Physician Orders, dated (MONTH) (YEAR), revealed an order, dated 05/22/18, for use of sling lift for transfers to enable safe transfers related to weakness. Review of Resident #2's Care Plan, dated 05/28/18, revealed he/she was at risk for injury related to decreased mobility, right side flaccid [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. Interventions listed included to transfer the resident with a mechanical lift with two (2) persons. Review of Resident #2's Nurses Notes, dated 06/28/18, revealed the Assistant Director of Nursing (ADON) documented the resident was on the floor, face down, at 4:30 PM. An assessment was completed and the resident had a skin tear to the right forearm, knee, hand, and forehead. The resident denied pain. The physician and family were notified and the resident was sent to the hospital. Review of the hospital Emergency Physician Record, dated 06/28/18, revealed Resident #2 was diagnosed with [REDACTED]. Observation, on 09/04/18 at 1:35 PM, revealed Resident #2 was in bed and had no concerns with his/her care. Interview with CNA #3, on 09/05/18 at 9:35 AM, revealed on 06/28/18, she attempted to transfer Resident #2 alone using the mechanical lift because she was unable to locate another staff member to help. She stated the strap of the sling came off the hook when she pulled the lift away from the bed and the resident slid out of the sling to the floor. She stated she immediately ran to find a nurse and Registered Nurse (RN) #2 and other staff returned with her to the room, assessed the resident, and assisted the resident to bed. Further interview with CNA #3 revealed mechanical lifts required two (2) staff assist to ensure resident safety and prevent potential falls, injury, fractures, or death. Interview with CNA #8, on 09/04/18 at 3:00 PM, revealed staff should always wait for a second person to assist with a mechanical lift because a resident could fall out of the sling or the lift could turn over. Interview with RN #2, on 09/05/18 at 11:45 AM, revealed on 06/28/18, when CNA #3 notified her of Resident #2's fall, she went to the resident's room, assessed the resident, notified the physician, and transferred the resident to the ER. Further interview with RN #2, on 09/05/18 at 2:00 PM, revealed the purpose of the care plan was to guide care for the resident. She stated Resident #2's care plan was not followed for transfers. Interview with the Assistant Director of Nursing (ADON), on 09/05/18 at 3:41 PM, revealed CNA #3 was interviewed regarding the incident and the CNA did not follow the facility's mechanical lift procedure. Interview with the Director of Nursing (DON), on 09/05/18 at 3:13 PM, revealed CNA #3 should have had another person assist her with the transfer and stated the CNA did not follow the resident's care plan. She stated she had not identified any concerns with improper use of mechanical lifts prior to Resident #2's fall. Interview with the Administrator, on 09/06/18 at 12:50 PM, revealed CNA #2 had not followed the facility's policy and procedure for transfers with a mechanical lift. The facility implemented the following actions to correct the deficient practice: 1. The Medical Director was notified of the incident on 06/28/18. 2. The facility reassessed Resident #2's fall risk on 06/28/18 and reviewed the care guide and care plan to verify the correct transfer status. Notifications to family, physician, and Administrator were made according to policy. 3. The Unit Manager (UM) reviewed and verified sixty-three (63) resident care guides and care plans for correct transfer status on 06/30/18. 4. The facility re-educated all staff present in the building on 06/28/18 regarding proper Mechanical Lift Procedure. The UM and Assistant Director of Nursing (ADON) conducted the training. The education included a return demonstration using the manufacturer's Total Lift Procedure skills check off. Twenty-two (22) staff members were present and educated. The facility re-educated thirty-two (32) additional staff members regarding Mechanical Lift Procedure on 06/29/18, 06/30/18, 07/02/18, and 07/03/18 prior to the start of the staff members shift and prior to providing direct care. Completion of the training occurred on 07/03/18. 5. The facility implemented a Lift Binder, located on each nursing unit. Nursing staff would refer to the binder to ensure the correct lift and sling size was used to transfer a resident. The UM and ADON would review new physician orders [REDACTED]. 6. The Maintenance Director inspected two (2) of two (2) mechanical lifts in the building on 06/28/18 and completed an inspection of Resident #2's sling. The facility would conduct monthly inspections of the mechanical lifts and inspections of slings each time they were washed, and would be ongoing. 7. The UM, ADON, and Director of Nursing (DON) audited staff performing transfers using a mechanical lift to ensure the transfer was performed according to the facility procedure and the resident care guide. Audits started on 06/30/18 and were completed twice a shift for one (1) week, once a shift for one (1) week, and daily for one (1) week. The audits were completed on 07/20/18. 8. The Administrator conducted an emergency Ad Hoc QA Meeting with the care team on 06/28/18. The monthly QA was conducted on 07/02/18 and Fall Committee Meetings were held on 07/05/18 and 07/25/18 to review the progress and findings of the Action Plan. The State Survey Agency validated the facility implemented the following: 1. Interview with the Administrator, on 09/06/18 at 12:50 PM, revealed the Medical Director was on site at the time of the incident on 06/28/18 and participated in the Ad Hoc meeting. 2. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed she notified the Administrator of the incident and sent Certified Nursing Assistant (CNA) #3 home on 06/28/18. Review of the clinical record for Resident #2 revealed the care plan was reviewed and revised on 06/28/18. The Fall Care Plan reflected an intervention for transfers with a mechanical lift with two (2) persons. A Fall Investigation and Fall Risk Assessment were completed on 06/28/18. Further review revealed the family and physician were notified of the fall on 06/28/18. 3. Interview with the UM, on 09/05/18 at 4:15 PM, revealed she reviewed and verified the CNA care guides and care plans for sixty-three (63) residents to ensure the correct transfer requirements were in place. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed her and the UM verified all CNA care guides and resident care plans to ensure accuracy. Review of the clinical records for Resident #1, #2, #3, #4, and #5 revealed the care guides and care plans reflected the correct transfer status. 4. Interview with CNA #1, on 09/06/18 at 3:00 PM, revealed she was retrained on mechanical lifts. She stated the training covered how to attach the sling, color coding related to sling size, and weight limits of the slings. She stated a binder was located on each hall to refer to resident lift requirements. CNA #1 revealed mechanical lifts required two (2) persons at all times. Interview with Hospitality Aide #1, on 09/06/18 at 3:12 PM, revealed she was trained on the use of mechanical lifts. She stated two (2) people were required to perform mechanical lifts. Interview with Licensed Practical Nurse (LPN) #1, on 09/06/18 at 3:06 PM, revealed staff were re-trained on mechanical lifts on the evening of Resident #2's fall. The LPN stated staff was required to demonstrate the correct lift procedure for competency. He stated two (2) persons must be present at all times when performing a mechanical lift. Interview with Registered Nurse (RN) #1, on 09/06/18 at 3:03 PM, revealed the facility had conducted training on lifts within the last two (2) to three (3) months. She stated the training included correct use of the lift, safety hazards, and verification of the sling attachment. The RN stated two (2) persons were required at all times to perform lifts. Interview with LPN #2, on 09/04/18 at 2:40 PM, revealed two (2) persons were required at all times to perform mechanical lifts to ensure resident safety and prevent potential falls. The LPN revealed the facility retrained and conducted competency checks with all nursing staff on the correct use of mechanical lifts following Resident #2's fall. Interview with the UM, on 09/05/18 at 4:15 PM, revealed the facility removed the lift/sling from service immediately following the incident and retrained all staff on-site regarding the mechanical lift policy and procedure. The UM revealed all staff was required to complete the mandatory training prior to working their next scheduled shift. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed an Action Plan was initiated on the evening of 06/28/18 and all nursing staff on-site was educated regarding transfer techniques and correct use of the lift. She stated all staff were educated prior to their next scheduled shift and were required to perform a return demonstration to determine competency. Record review revealed fifty-four (54) of fifty-four (54) staff was trained on proper Mechanical Lift Procedure by 07/03/18. 5. Interview with CNA #8, on 09/04/18 at 3:00 PM, revealed she referred to the Lift Binder to determine the transfer requirements for a resident. She stated the book was located at the CNA kiosk and contained the lift information and care needs of each resident. Interview with CNA #9, on 09/04/18 at 2:15 PM, revealed she used the Lift Binder to determine a resident's transfer status. She stated the Lift Binder indicated the type of lift and sling size to be used for any resident that required a mechanical lift. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed the facility implemented a binder for each hall to identify residents requiring a mechanical lift. Interview with the DON, on 09/05/18 at 3:13 PM, revealed the facility implemented Lift Binders that contained a list of residents who required mechanical lifts, a picture of each resident, the type of lift to be used, and the appropriate sling size. Review of the Lift Binder revealed Resident #2 was listed in the book and included his/her picture and lift requirements for two (2) person assist with mechanical lift and a green sling. The facility's lift procedure and a list of sling weight limits were also in the binder. 6. Interview with the Maintenance Director, on 09/04/18 at 4:25 PM, revealed he inspected the lift and sling involved in Resident #2's fall on 06/28/18 and found no defects. The Director stated he also inspected the West Hall lift on 06/28/18 and found no defects. He revealed mechanical lifts were inspected monthly and as needed to assess for wear and damage. Record review revealed the Maintenance Director inspected two (2) mechanical lifts on 06/28/18, including slings. 7. Interview with the ADON, on 09/05/18 at 3:41 PM, revealed audits were conducted to monitor staff utilizing the mechanical lifts to ensure two (2) staff was present. Record review revealed audits of staff using mechanical lifts were conducted 06/30/18 to 07/20/18. 8. Interview with the UM, on 09/05/18 at 4:15 PM, revealed the facility held an emergency Ad Hoc Quality Assurance (QA) meeting with the Medical Director on the evening of the incident to review the findings of the investigation and discuss an Action Plan. Interview with the DON, on 09/05/18 at 3:13 PM, revealed the audit findings for lift transfers were reviewed during weekly and monthly QA meetings until the audits were completed on 07/20/18. She stated no further concerns were identified during the audits and the facility determined Resident #2's fall was an isolated incident. Interview with the Administrator, on 09/06/18 at 12:50 PM, revealed the facility held an Ad Hoc QA meeting on 06/28/18 to review Resident #2's fall, the investigation, and the Action Plan. The Administrator stated the Medical Director participated in the Ad Hoc meeting. The Administrator revealed there were no new issues identified as a result of the lift audits and he felt the incident involving Resident #2 was an isolated event. He stated the facility's date of compliance was 06/29/18, as all staff working on 06/28/18 was educated that day and no other staff was allowed to work until they received the education.