Every finding on record at Hartsville Convalescent Center

Based on facility policy review, facility investigation review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent 1 of 6 (Resident #1) residents reviewed for wandering behaviors from exiting the building without staff supervision. Resident #1 was a vulnerable, cognitively impaired Resident with a history of wandering behaviors and wore a wander guard on his person and on his wheelchair. On 10/28/2024, an order was written to discontinue the wander guard from Resident #1's wheelchair. The facility discontinued Resident #1's wander guard from his wheelchair and from his person. Resident #1 eloped from the facility on 11/27/2024, 29 days after the wander guard was discontinued from his wheelchair and his person. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy (IJ) when Resident #1, eloped from the facility on 11/27/2024, and was found approximately 0.3 miles from the facility at a discount retail store. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide adequate supervision of a vulnerable, cognitively impaired resident to prevent an incident of elopement. The Owner, Administrator, Registered Nurse (RN) Consultant, and Director of Nursing (DON) were notified of Immediate Jeopardy on 8/8/2025 at 6:37 PM, in the Conference Room. The facility was cited F689 at a scope and severity of J which is substandard quality of care. The IJ began on 11/27/2024 through 12/5/2024. The IJ was removed on 12/6/2024. The corrective action plan for the IJ was validated onsite by surveyor on 8/11/2025. The facility was cited past noncompliance (PNC) for F-689 and is not required to submit a Plan of Correction. The finding include: 1. Review of the facility policy titled, Elopement and Wandering Residents, dated 4/16/2021, revealed .The facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.'Wandering' is random or repetitive locomotion that may be goal-directed.'Elopement' occurs when a resident leaves the premises or a safe area without authorization.The facility is equipped with door locks/alarms to help avoid elopements.Staff are to be vigilant in responding to alarms in a timely manner.The facility shall establish and utilize a systemic approach to monitoring and managing residents.Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team [IDT].when repeated elopement attempts occur, after the facility has exhausted possible care.Any staff members becoming aware of a missing resident will alert personnel using facility approved protocol. Review of the facility policy titled, Wandering Residents dated 12/6/2024, revealed Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement .All residents at risk for harm because of wandering (elopement) will be assessed by the inter disciplinary care planning team .current MDS [ Minimum Data Set] .will be reviewed .The resident's care plan will be modified .All residents at risk for harm because of wandering (elopement) will be placed on first floor with [Named] security ankle monitor placement. Once a wander guard has been placed on a resident, any removable must be approved by the QAPI [Quality Assurance and Performance Improvement] committee.Any resident with a wander guard must be accompanied by sitter, nurse, activity staff or family member to go to 2nd floor. Review of undated facility policy titled, Missing Resident Policy and Procedure, revealed .It is the policy of this facility, that all residents will remain safely contained within the confinement of the building and its perimeter.if a resident is unable to be found, and is suspected to be missing, the nurse in charge of that resident will announce over the intercom: CODE PURPLE. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including dementia, Major Depressive Disorder and Diabetes. Review of Physician's Telephone Orders dated 7/15/2024, revealed an order Per Recommendation of facility Psych [Psychiatric] services may discontinue Wanderguard [Wander Guard]. Review of Physician's Telephone Orders dated 8/12/2024, revealed Nurse Practitioner (NP) I had given an order .Wanderguard to wheelchair .check placement & functionality q [every] Monday . Review of the Intermediate Care Facility (ICF) Behavior Progress Note dated 8/12/2024, revealed Resident #1 attempted to exit the facility door and a wander guard was applied to his wheelchair. Review of Care Plan dated 8/16/2024, revealed .8/13/2024 Behavioral Symptoms.Wander Guard applied for wandering and exit seeking behavior.Re-applied to resident's WC [wheelchair], not his person. He is allowed sitting time on front porch when staff is present. He should re-enter the facility when staff comes inside. Review of the Resident Progress Notes dated 8/26/2024, reviewed NP I documented .Wander guard in place . Review of September 2024 Medication Administration Record (MAR) revealed an order to check Resident #1's Wander Guard every week on Monday for Function and Placement. Review of Psychiatric Periodic Evaluation for Resident #1 dated 10/15/2024, revealed NP R documented, .continue to monitor for wandering and any increase of anxiety. Review of the Annual MDS assessment dated [DATE], revealed a Brief Interview for Mental Status score of 7, which indicated Resident #1 had severe cognitive impairment. Review of the Physician's Order for Resident #1 dated 10/28/2024, revealed NP I had given a verbal order to .DC Wanderguard [wander guard], to wheelchair-no longer indicated. Review of the Resident Progress Notes dated 10/28/2024, revealed the MDS Coordinator documented .Wander Guard DC'd [discontinued] . The wander guard was DC'd from the Care Plan on 10/28/2024. Review of the October 2024 MAR for Resident #1 revealed the wander guard was discontinued to his wheelchair on 10/28/2024. The wander guard was signed out on the MAR as checked on 10/30/2024. Review of the Resident Progress Notes dated 10/30/2024, revealed NP I documented Resident #1 was .Intrusive and impulsive with behaviors . Review of Resident Progress Notes dated 10/30/2024, revealed the MDS Coordinator documented .Wander Guard back in place at time of ARD [Assessment Reference Date] . Review of the Progress Notes dated 10/31/2024, revealed a previous note from Psych NP R dated 10/30/2024, had been edited to reflect Resident #1 was .Intrusive and impulsive with behaviors.Wander Guard . Review of November 2024 Medication Record revealed an order to check wander guard every week on Mondays for function and placement and Wander Guard to wheelchair. A line was drawn through the order on the MAR and .DC'd 10/28/2024 . was documented. Review of the Psychiatric Periodic Evaluation for Resident #1 dated 11/12/2024, revealed NP R documented recommendations to monitor due to Resident #1 being a risk of elopement. An addendum was added by NP R noting she was unaware that Resident #1's wander guard had been removed by another provider (NP I) on 10/28/2024. The addendum was added on 12/16/2024, and electronically signed by NP R. Review of the facility investigation dated 11/27/2024, revealed the Sherriff's Department received a call at 3:48 PM from a community member. The community member then went to the facility to notify staff that a suspected Resident (Resident #1) had left the building and was walking on the narrow shoulder of the road toward the discount retail store. Certified Nurse Assistant (CNA) M notified the Nursing Supervisor then went to search for Resident #1 while the supervisor initiated the protocol for a missing resident. On 11/27/2025 at 3:54 PM, law enforcement arrived at the discount retail store, which was approximately 0.3 miles from the facility, and returned Resident #1 to the facility at 3:58 PM. Review of the (Named) Sheriff Department Call for Service Card dated 11/27/2024 at 3:48 PM, revealed a deputy was dispatched to the scene at 3:53 PM. Resident #1 was returned to the facility by Deputy #1 at 3:58 PM. During a telephone interview on 8/7/2025 at 1:10 PM, the Psychologist stated Resident #1 had historically experienced fixed thoughts of going home which caused the Psychologist to think Resident #1 was an elopement risk. During an interview on 8/7/2025 at 3:00 PM, NP I was asked what the criteria was for removal of an ankle monitor. NP I stated, .If the resident was wandering or exit seeking, the Wander guard will remain in place .If the resident has been deemed immobile then we would remove the ankle monitor .If the ankle monitor is removed after having been placed for psychiatric reasons, there usually would be a discussion amongst the IDT [inter disciplinary team] to see whether it [removal of wander guard] was a good idea .I recall writing an order to remove the monitor from the wheelchair and did not recall writing an order to remove the monitor from [Resident #1's] person . During an interview on 8/7/2025 at 4:00 PM, the MDS Coordinator stated the former DON instructed her to sign off on the order to remove the ankle monitor and to take it off of the Care plan and she did so. The MDS coordinator did not physically take the wander guard off Resident #1 and did not know who removed the wander guard. During a phone interview on 8/11/2025 at 4:15 PM, NP R stated, .I was in the building the day he [Resident #1] eloped. I passed by him upstairs and did not think anything about it.The Director of Nursing would allow him upstairs to do things [activities and porch time].I observed [Named Resident #1] being brought downstairs by nursing.I asked where [Named Resident #1's] ankle monitor was .when I interviewed the resident.he spoke about his wife dying and stated he wanted to go home.He [Resident #1] said that he was going to check on his wife and that he was going to his old house. During an interview on 8/11/2025 at 5:00 PM, the DON verified the facility implemented a policy revision related to the wander guard which stated if there was a reason to discontinue a wander guard, it would be brought before the QAPI meeting to collaboratively decide whether the wander guard monitor needed to be removed. The Plan of Correction was validated by the surveyor through policy review, medical record review, door checks, in-service review, audit review of Door & Gate Keypad Logs, Maintenance Check on Exit Door log review, Elopement Drill review, observations of residents with wander guards, and interviews on all shifts. Removal Plan of Correction: Resident #1 - (Named Resident #1) 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was returned to the facility at approximately 4:02 pm by the police (TAB# 2). On 11/27/2024 a physical assessment was completed by charge nurse including head to toe skin assessment and pain assessment (TAB# 5). (Named Resident #1) attire and footwear noted on 11/27/2024by licensed nurse to be appropriate for weather- Temperature was 61 degrees, and resident was wearing two shirts, two pair of pants, and two pair of socks and shoes (TAB# 9-MDS Statement). On 11/27/24 MD and resident representative notified by the Director of Nursing (TAB# 9). On 11/2712024 4:05 (Named Resident #1) returned to his room on the 1st floor with wander guard placed on Lt. (left) ankle and was placed on every 1 hour checks 11/27/24 and continued until 12/16/23 (TAB# 17 & 18). On 11/27/2024 4:30 PM Psych evaluation completed by Psych NP (TAB# 4). Psychosocial follow-up completed post event to evaluate for psychosocial distress by Psych NP, Medical NP, on 12/2/2024, Director of Nursing on 11/28/2024. (TAB#4 & 9). NP visit completed on12/5/24 (TAB# 4). Resident #1's Care Plan reviewed and updated by members of the Clinical Leadership Team on 11/28/2024 as indicated (TAB# 6). 2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Headcount completed of all residents on 11/27/2024 by clinical staff & Nursing Supervisor post event (TAB# 15). Front Door assessed by Maintenance Director 11/28/2024 post event- door assessed to be functioning properly (TAB# 9). Beginning 11/28/2024 and completed on 11/29/2024, all residents who were assessed for elopement their Care Plans were updated as indicated by the MOS Coordinator (TAB# 6). Elopement Risk Binder reviewed by Nursing Supervisor on 11/27/2024, to ensure any resident(s) at high risk for elopement was in book (TAB #11). Clinical Team, the Director of Nursing, Nursing Supervisor, MDS Nurse and the Healthcare Consultant, reviewed the following policies for needed changes on 12/2/2024-1) Elopement & Wandering Residents, 2) Protocol-Wandering Resident Management Elopement Prevention, 3) Determining resident Placement on admission for Safety and Appropriate Care, and 5) Wandering Residents. Changes were made in the policy Wandering Resident -1) Once wander guard is applied can only be removed when the request for removeable is approved by QAPI Committee and 2) Any resident with a wander guard must be accompanied by sitter, nurse, activity staff or family member to go to 2nd floor (TAB#20). All residents considered to be high risk for elopement, either from elopement assessment, prior relevant history and/or current behaviors will be placed on 1st floor, unless contraindicated as stated in PoUcy- (Policy) Determining Resident Placement on admission for Safety and Appropriate Care (Tab# 20). Maglock system functionality is checked on all doors monthly by the Maintenance Director and was checked on front door 11/29/24 and verified by the Administrator on 11/29/2024 (TAB# 9). On12/2/2024 the Maintenance Director changed the front door code. A sign was placed on the front door by the Administrator on 12/2/2024 concerning the change in visiting times and process for entering and exiting the front door. A memo was sent to family members and Residents on this change (Tab# 13). On 11/27/24 the Charge nurses and Nursing Supervisor conducted Elopement Risk Assessments on residents with a wander guard bracelet and all the other residents to ensure all residents have been properly placed within the facility (TAB #12). 3) What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. Beginning 11/27/24 and ending12/5/24 the Nursing Supervisor and/or Administrator conducted multiple mandatory in-service with all nurses(RN,LPN, CNAs) including Agency staff and facility employee concerning resident safety i.e. elopement assessment, prevention, identifying exit seeking behavior, monitoring of residents at high risk, what to do if a resident is displaying exit seeking behavior and what to do if an elopement occurs, Abuse, and review of the policies-Elopement & Wandering Residents, 2) Protocol­ Wandering Resident Management Elopement Prevention, 3) Wandering Residents. These in-services were either in-person, in a classroom setting or 1:1 either in person or by telephone. Any staff missing in-services will not work until they receive training. Any staff who fail to comply with the points of the in-services will be further educated and/or progressively discipline will begin as indicated (Tab# 14). After initial orientation121212024, agency staff will receive elopement education via the agency orientation and tracked daily Monday-Friday in morning meeting by the Administrator. (Stand-up Minute Book). New hires will continue to receive elopement education during new hire orientation. The Administrator will track this education (Stand-up Minute Book). Residents with new, continued, worsening wandering/exit seeking behavior will be reviewed daily in clinical meeting by the IDT, Monday - Friday x4 weeks. On the weekends, this review will be done daily by the clinical leader on call on weekends. This review will include adding care planned interventions if indicated to decrease the risk of elopement (TAB IDT Clinical Meetings Book). Beginning 11/28/24 the DON &/or Nursing Supervisor will monitor the visits of the assessments are conducted by the Psych NP for Resident #1 to ensure treatment and care is provided post elopement (Tab # 4). Elopement drills were conducted by Administrator and Nursing Supervisor monthly for 3 months beginning 12/2/2024 as verified by written reports. (TAB# 16). The Director of Nursing changed the monitoring of Wander guard bracelets from weekly to every shift on the Resident's Medication Administration Record beginning 12/2/24 (Tab# 19). Beginning 12/2/24 the Administrator will monitor the compliance of entering and exit of the front door changes during the Morning Stand-up meeting. Any non-compliance or violation of the front door signage or changes will be addressed immediately and document each violation on an investigation form (See Stand-up Meeting minutes). Beginning 12/2/24 the Nursing Supervisor will review the education delivered to all staff and confirm all staff have been educated, including Agency staff. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. A one hundred percent of all education sign-in sheets will be reviewed by nursing supervisor &/or DON to ensure that all staff have been properly educated related to the Elopement and Wandering Resident policies and Interventions communicated. The results of the review will be presented to the full Quality Committee to determine if the issue has been resolved or if the initiative should continue. 4) How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Ad Hoc QAPI meetings were held weekly times 2 weeks beginning 12/3/24 to review the action plan and needed changes and the monthly QAPI meeting was conducted the last week of December. At the OAPI meetings the results of all monitoring by the DON, nursing managers, and Administrator will be reviewed, however any concerns identified will be addressed as discovered, including any needed education and/or progressive discipline. At the December meeting the DON, Nursing Managers, and Administrator will report monitoring outcomes of in-services, care plans, IDT meetings, and Stand-up meetings, at the monthly OAPI Committee meetings. The Administrator will report to the Owner the monitoring outcomes on a monthly basis.

Based on facility policy review, facility fall investigation review, medical record review, and interview the facility failed to implement a comprehensive person-centered care plan intervention for 1 of 8 (Resident #39) sampled residents reviewed for falls. The facility's failure to implement a care plan intervention for a fall resulted in actual harm when Resident #39 fell from a sloped ramp for the second time. The findings include: Review of the facility policy titled, FALL PREVENTION AND MANAGEMENT, dated 10/2023 revealed, .A Fall Prevention and Management Program is used to provide a safe environment for residents. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls and/or decrease the likelihood of injury .Nursing Management is responsible for updating care plan related to fall risk, interventions and/or injury related to falls .Review and update causative factors, interventions, and care plan .Pattern of falls, when identified, should be thoroughly evaluated for underlying causes so that a proactive approach and interventions can be implemented to decrease likelihood of further falls . Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 12/2016 revealed, .The comprehensive, person-centered care plan will .Include measurable objectives and timeframes .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .reflect treatment goals, timetables and objectives in measurable outcomes .Aid in preventing or reducing decline in the resident's functional status and/or functional levels .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . Review of the medical record revealed Resident #39 admitted to the facility on [DATE] with diagnoses which included Dementia, acquired absence of left upper limb related to machinery injury, and Chronic Ischemic Heart disease. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review revealed Resident #39 had upper extremity impairment on one side and mobility device was a wheelchair. Further review revealed Resident #39 had a fall in the last month and in the last 2-6 months. Review of the Incident/Accident Report for Resident #39 dated 6/17/2024 at 5:00 PM, revealed .RSD [resident] took off down ramp in his w/c [wheelchair] independently and flipped his w/c to the L [left] side Corrective/Preventative measures taken to reduce risk of reoccurrence of recent fall .Resident unable to use ramp by self; take him to DRoom [dining room] for meals, Return to common area after meals . Further review revealed an Activities of Daily Living (ADL) assessment dated [DATE] with comments, .6/17/24 [2024] Educated CNA [certified nursing assistant] that resident needs assist to manage ramp and should not be on ramp without staff . Review of the undated Certified Nursing Technician (CNT) Point of Care Documentation (how CNTs are to provide care to residents) revealed Resident #39 required staff assistance to navigate the ramp in the facility. Review of the Incident Scene Statement dated 6/17/2024 for Resident #39 revealed, .Rsd [resident] did not state what they were doing They just started down the ramp and the chair got away from them . Review of the comprehensive care plan for Resident #39 revealed .Problem Start Date: 06/17/2024 .Falls .at risk for falling R/T [related to] advanced dementia, poor safety awareness, terminal status and LUE [left upper extremity] amputation status .Approach Start Date .6/18/2024 .Staff education on resident use of ramp in main area. Resident is unable to manage ramp up or down to main DR [dining room] level without staff assistance . Review of the Incident/Accident Report for Resident #39 dated 6/22/2024 at 9:45 AM, revealed, .Resident observed coming in w/c down ramp at upstairs nurses [nurse's] station; saw him fall forward out of w/c; L side of forehead /c [with] abrasion . Review of the June 2024 Medication Administration Record (MAR) revealed on 6/22/2024 at 10:15 AM Tylenol 325 mg (milligram) 2 tablets were given my mouth for forehead. The MAR revealed Resident #39 experienced pain with the fall. Review of the comprehensive care plan for Resident #39 revealed .Problem .Falls .Approach Start Date .6/22/2024 fall with .skin abrasion to forehead: Resident to not be on upper ramp level unless in DR [dining room] for meals. Staff is to escort resident up ramp to DR [dining room] and then down ramp to common area after meal. Sign placed at nursing station to alert staff . Review of the Rehabilitation Screen dated 6/24/2024 revealed, .Fall date 6/22/24 [2024] @ [at] 9:45 a.m. [AM] Findings: Pt. [patient] unable to recall what caused incident. Nursing reports pt self propelled WC [wheelchair] down ramp before nursing could reach him and fell out of chair hitting his head . Observation of the dining room on the 2nd floor on 7/15/2024 at 1:00 PM, revealed a ramp leaving the dining room going down in front of the nurse's station leading into the common area on the 2nd floor. Observation in common area on the 2nd floor on 7/15/2024 at 1:10 PM, revealed Resident #39 sitting in his wheelchair watching television. During a telephone interview on 7/16/2024 at 12:04 PM, Family Member (FM) B stated, . [Named Resident #39] had two falls down the ramp. I finally had to ask the facility if he could eat in the big open common area instead of the dining room. It wasn't safe for him to go down that ramp . During an interview on 7/17/2024 at 11:00 AM the Director of Nursing (DON) was asked why the staff was not assisting Resident #39 down the ramp when he had the second fall on 6/22/2024. The DON stated, .the Certified Nursing Assistant [CNA] was agency she didn't know he needed assistance down the ramp . The DON was asked should the agency staff be aware of the care plan interventions to prevent falls for a resident. The DON stated, .well it was on the care plan, the agency staff could have reviewed the care plan . During a telephone interview on 7/17/2024 at 11:30 AM, Registered Nurse (RN) C stated, .I work PRN [as needed]. I was there when [Named Resident #39] fell down the ramp on 6/22/2024. The CNA and I wasn't made aware that he needed assistance going down the ramp. I found that out after his fall .I got a report from a nurse that day, but nothing was mentioned about his previous fall down the ramp and needing assistance when going down the ramp .

Based on facility policy review, facility fall investigation review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent an accident for 1 of 8 (Resident #39) sampled residents reviewed for accidents which resulted in actual Harm. On 6/17/2024, Resident #39, a vulnerable cognitively impaired resident, propelled himself down a sloped ramp and flipped his wheelchair. Staff were educated that Resident #39 could not propel down the ramp without staff assistance. On 6/22/2024, Resident #39 once again propelled himself down the ramp without staff assistance, flipped his wheelchair, and received an abrasion to the left side of his forehead. The findings include: Review of the facility policy titled, FALL PREVENTION AND MANAGEMENT, dated 10/2023 revealed, .A Fall Prevention and Management Program is used to provide a safe environment for residents. This program is designed to identify residents at risk of falls; define interventions for the prevention of falls and/or decrease the likelihood of injury .Nursing Management is responsible for updating care plan related to fall risk, interventions and/or injury related to falls .Review and update causative factors, interventions, and care plan .Pattern of falls, when identified, should be thoroughly evaluated for underlying causes so that a proactive approach and interventions can be implemented to decrease likelihood of further falls . Review of the medical record revealed Resident #39 admitted to the facility on [DATE] with diagnoses which included Dementia, acquired absence of left upper limb related to machinery injury, and Chronic Ischemic Heart Disease. Review of the Incident/Accident Report for Resident #39 dated 6/17/2024 at 5:00 PM, revealed .RSD [resident] took off down ramp in his w/c [wheelchair] independently and flipped his w/c to the L [left] side Corrective/Preventative measures taken to reduce risk of reoccurrence of recent fall .Resident unable to use ramp by self; take him to DRoom [dining room] for meals, Return to common area after meals . Further review revealed an Activities of Daily Living (ADL) assessment dated [DATE] with comments, .6/17/24 [2024] Educated CNA [certified nursing assistant] that resident needs assist to manage ramp and should not be on ramp without staff . Review of the undated Point of Care (document that provides information on how to care for the resident for Certified Nursing Technicians - CNT) for Resident #39 revealed, .no ramp navigation /s [without] staff . Review of the Incident Scene Statement dated 6/17/2024 for Resident #39 revealed, .Rsd [resident] did not state what they were doing They just started down the ramp and the chair got away from them . Review of the comprehensive care plan for Resident #39 revealed .Problem Start Date: 06/17/2024 .Falls .at risk for falling R/T [related to] advanced dementia, poor safety awareness, terminal status and LUE [left upper extremity] amputation status .Approach Start Date .6/18/2024 .Staff education on resident use of ramp in main area. Resident is unable to manage ramp up or down to main DR [dining room] level without staff assistance . Review of the Rehabilitation Screen for Resident #39 dated 6/18/2024, revealed .Findings .nursing reports that [Named Resident #39] went down WC [wheelchair] flipped @ [at] bottom of ramp. Fall was witnessed and [Named Resident #39] did not hit his head . Review of the Incident/Accident Report for Resident #39 dated 6/22/2024 at 9:45 AM, revealed .Resident observed coming in w/c down ramp at upstairs nurses [nurse's] station; saw him fall forward out of w/c; L side of forehead /c [with] abrasion . Review of the POST FALLS NURSING assessment dated [DATE], revealed .Resident observed coming in w/c down ramp @ [at] upstairs nurses [nurse's] station; saw him fall forward out of w/c; L side of forehead /c abrasion . Review of the POST-FALL DOCUMENTATION dated 6/22/2024, for Resident #39 revealed .RSD .in dining area in his w/c .has abrasion to (Lt) [left] forehead . Review of the Medication Administration Record (MAR) dated June 2024 revealed on 6/22/2024 at 10:15 AM, Tylenol 325 mg (milligram) 2 tablets were given by mouth for forehead. Review of the June MAR revealed Resident #39 experienced pain with the fall on 6/22/2024 and received pain medication. Review of the comprehensive care plan for Resident #39 revealed .Problem .Falls .Approach Start Date .6/22/2024 fall with .skin abrasion to forehead: Resident to not be on upper ramp level unless in DR for meals. Staff is to escort resident up ramp to DR and then down ramp to common area after meal. Sign placed at nursing station to alert staff . The comprehensive care plan reflected Resident #39 needed continued assistance with going up and down the ramp. Review of the Rehabilitation Screen dated 6/24/2024, revealed .Fall date 6/22/24 [2024] @ 9:45 a.m. Findings: Pt. [patient] unable to recall what caused incident. Nursing reports pt self propelled WC [wheelchair] down ramp before nursing could reach him and fell out of chair hitting his head . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #39 had upper extremity impairment on one side and mobility device was a wheelchair. Further review revealed Resident #39 had a fall in the last month and in the last 2-6 months. Observation of the dining room on the 2nd floor on 7/15/2024 at 1:00 PM, revealed a ramp leaving the dining room going down in front of the nurse's station leading into the common area (large open area with couch, television, and dining area for residents to sit). Observation in the common area on the 2nd floor on 7/15/2024 at 1:10 PM, revealed Resident #39 sitting in his wheelchair watching television. During a telephone interview on 7/16/2024 at 12:04 PM, Family Member (FM) B stated, .[Named Resident #39] had two falls down the ramp. I finally had to ask the facility if he could eat in the big open common area instead of the dining room. It wasn't safe for him to go down that ramp . During an interview on 7/17/2024 at 11:00 AM, the Director of Nursing (DON) was asked what was put in place to prevent [Named Resident #39] from having another accident on the ramp after the first fall on 6/17/2024. The DON stated, .The staff should assist him when he uses the ramp .the Certified Nursing Assistant [CNA] was agency [an employee from a working staff agency] she didn't know he needed assistance down the ramp .I done [did] some education with the staff . The DON was asked should the agency staff be aware of the care plan interventions to prevent falls for a resident. The DON stated, .well it was on the care plan, the agency staff could have reviewed the care plan . During a telephone interview on 7/17/2024 at 11:30 AM, Registered Nurse (RN) C stated, .I work PRN [as needed]. I was there when [Named Resident #39] fell down the ramp on 6/22/2024. The CNA and I wasn't made aware that he needed assistance going down the ramp. I found that out after his fall .I got a report from a nurse that day, but nothing was mentioned about his previous fall down the ramp and needing assistance when going down the ramp .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by unlabeled and undated food items, failed to maintain 1 of 2 coolers in proper working order to prevent potential cross-contamination to stored food, and failed to keep a temperature log and a thermometer for all personal refrigerators for 4 of 4 (Resident #2, #3, #11, and #42) sampled residents reviewed. The facility had a census of 53. The findings include: Review of the facility policy titled, Food Receiving and Storage, dated 10/2017 revealed, .All foods stored in refrigerator or freezer will be covered, labeled and dated (use by date) .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements . Review of the facility policy titled, Maintenance Service, dated 8/2008 revealed, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the .equipment in a safe and operable manner at all times . Review of the facility policy titled, Resident Refrigerators, dated 1/16/2024, revealed .it is the policy of the facility to ensure safe and sanitary use of any resident-owned refrigerators .Policy Explanation and Compliance Guidelines .1. b. The refrigerator maintains proper temperatures .2. Nursing staff or designee shall record refrigerator temperatures daily on a temperature log maintained in the Director of Nursing office .a. A thermometer shall remain in the refrigerator .b. Temperatures will be at or below 41-degree F [Fahrenheit] .3. Housekeeping staff shall clean the refrigerator weekly and discard any foods that are out of compliance .4. b. Leftovers shall be dated upon receipt and discarded within three days . Observation in the Kitchen on 7/15/2024 at 11:15 AM, revealed a bag of 15 [NAME] unlabeled and undated in the reach in cooler. Continued observation revealed clear liquid in a plastic container with drops of condensation falling into the container from the top of the cooler. During an interview on 7/15/2024 at 11:17 AM, the Interim Dietary Manager stated, .the [NAME] should be labeled and dated .I was not notified the cooler was dripping. I will let the maintenance man know about the cooler . Review of the medical record revealed Resident #2 was readmitted to the facility on [DATE] with diagnoses which included Paraplegia [the inability to voluntarily move the lower parts of the body], Arthropathy, and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed, a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Review of the refrigerator temperature log for Resident #2, revealed no temperatures documented since 1/2/2024. No further temperature logs were provided for Resident #2's refrigerator. Observation of Resident #2's room on 7/16/2024 at 11:25 AM, revealed a personal refrigerator with no temperature log present. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Diverticulosis of large intestine without perforation or abscess with bleeding, Unspecified Intellectual disabilities, and Essential (Primary) Hypertension. Review of the Annual MDS assessment dated [DATE] for Resident #3 revealed, a BIMS score of 12 which indicated moderate cognitive impairment. Review of the refrigerator temperature log for Resident #3, revealed no temperatures documented since 1/4/2024. Observation of Resident #3's room on 7/16/2024 at 11:20 AM, revealed a personal refrigerator with no temperature log, no thermometer present, and two undated foam containers with food in it. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Coronary Artery Disease (CAD), and Congestive Heart Failure (CHF). Review of the Significant Change MDS assessment dated [DATE] for Resident #11 revealed, a BIMS score of 14 which indicated no cognitive impairment. Review of the refrigerator temperature log for Resident #11, revealed no temperatures documented since 1/1/2024. No further temperature logs were provided for Resident #11's refrigerator. Observation of Resident #11's room on 7/16/2024 at 11:15 AM, revealed a personal refrigerator in the room with no temperature log present. During an interview on 7/16/2024 at 1:45 PM, Licensed Practical Nurse (LPN) K confirmed Resident #11's personal refrigerator had no temperature log present, Resident #3's personal refrigerator had no temperature log present nor a thermometer, and Resident #2's personal refrigerator had no temperature log present. When asked where the temperature logs were located, LPN K stated, In a book at the nurse's station. When asked to see the logbook for temperatures, LPN K provided the surveyor with a copy of the temperature logs in the logbook. Continued interview revealed when asked if a residents' personal refrigerator should have a temperature log, LPN K replied, The DON would have that information. During an interview on 7/16/2024 at 2:30 PM, the House Supervisor was asked if a personal refrigerator should have a temperature log and a thermometer present. The House Supervisor replied, Yes. All resident refrigerators should have temperature logs present and a thermometer on the inside. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Essential (Primary) Hypertension, and Disease of Pericardium. Review of the Annual MDS assessment dated [DATE] for Resident #42 revealed, a BIMS score of 15 which indicated no cognitive impairment. Observation of Resident #42's room on 7/16/2024 at 4:15 PM, revealed a personal refrigerator with no temperature log present.

Based on facility policy review, hospital record review, medical record review and interview, the facility failed to provide the resident with a notice of the bed hold policy for 5 (Resident #4, Resident #31, Resident #41, Resident #46 and Resident #155) of 5 residents reviewed. The findings included: Review of the undated policy titled Bed Hold Policy revealed When a resident goes to the hospital from Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF), Medicaid/Medicare will not pay to hold the bed in the nursing home. If a resident or resident's representative (RR) wants to hold their bed as Private Pay while they are in the hospital, the Business Office must be notified immediately to decide. The charges for the bed hold will begin the day the resident is transferred to the hospital. If a resident .or their RR, does not make the arrangements as described above, they will be discharged , and all items will be boxed and placed in storage for a limited time .To ensure that the resident and/or resident's representative is knowledgeable of the facility's bed hold policy and that their wishes are addressed, the facility will provide this policy upon admission and any transfer to the hospital . Review of the medical record revealed Resident #4 was admitted to the facility with diagnoses which included Dementia with mood disturbance, Chronic Systolic Heart Failure and Schizoaffective Disorder. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated a severe cognitive impairment. Review of the Hospital medical record revealed Resident #4 was hospitalized on [DATE] for Forehead Scalp Laceration, Acute Kidney Injury, and Hyperglycemia. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus without complications, Obstructive Sleep Apnea, and Heart Failure. Review of the Annual MDS dated [DATE] for Resident #31 had a BIMS score of 9, which indicated moderate cognitive impairment. Review of the Resident face sheet for Resident #31 revealed he was hospitalized from 9/25/2023 through 10/2/2023. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with readmission on 7/8/2024 with diagnoses which included Acute on Chronic Systolic Heart Failure, Pleural Effusion and Chronic respiratory failure with hypoxia. Review of the Admission MDS dated [DATE] revealed Resident #41 had BIMS score of 13, which indicated no cognitive impairment. Review of the hospital record dated 6/5/2024 revealed Resident #41 was admitted to the hospital related to Respiratory Distress; Rib Fracture; and possible Pneumonia from 6/5/2024 to 6/13/2024. Review of hospital medical record revealed Resident #41 was admitted on [DATE] for altered mental status with behavioral issues. Resident #41 was admitted with hypoglycemia and large right pleural effusion. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Acute Kidney Failure, Acute on Chronic Systolic (Congestive) Heart Failure and Myasthenia Gravis without exacerbation. Review of the Admission MDS dated [DATE] revealed Resident #46 had a BIMS score of 15, which indicated no cognitive impairment Review of the face sheet revealed Resident #46 was admitted to the hospital from 4/29/2024 through 5/14/2024. Review of the medical record revealed Resident #155 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease (CKD), unspecified Stage 3. Review of the Quarterly MDS dated [DATE], revealed Resident #155 had a BIMS score of 15, which indicated no cognitive impairment. Review of the face sheet revealed Resident #155 was admitted to the hospital from 6/29/2024 through 7/8/2024. Review of the medical records for Resident #4, Resident #31, Resident #41, Resident #46, and Resident #155, revealed no bed hold policies were signed at the time of transfer from the skilled nursing facility. During an interview on 7/18/2024 at 3:13PM the Director of Nursing stated, .We just discuss the bed hold policy on admission. I don't think we have any .documentation .

Based on facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 2 of 5 sampled residents (Resident #41 and Resident #47) reviewed. The findings include: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated 6/2024 revealed, .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder .or a related condition receives care and services in the most integrated setting appropriate to their needs .PASARR Level I - initial pre-screening that is completed prior to admission .Negative Level I Screen - permits admission to proceed and ends that PASARR process unless a possible serious mental disorder .arises later .Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission .PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD [Mental Disorder] .or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs .Any resident who exhibits a newly evident or possible serious mental disorder .or a related condition will be referred promptly to the state mental health .authority for a level II resident review .Examples include .A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder .A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment . Review of the PASARR dated 6/12/2024 for Resident #41 revealed, .Symptoms/Behaviors .There are no known mental health behaviors which affect interpersonal interactions .There are no known mental health symptoms affecting the individual's ability to think through or complete tasks which he/she should be physically capable of completing .Mental Health Symptoms .None or No Symptoms experienced .Outcome .Level I Outcome: No Level II Condition-Level I Negative . Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Altered Mental Status and behavioral issues. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review revealed Resident #41 experienced delusions, physical and verbal behaviors directed toward others for 1-3 days during the assessment reference period. Further review revealed Resident #41 received antipsychotics over the last 7 days. Review of the Daily Skilled Nurse's Note for Resident #41 dated 7/1/2024 revealed, .RSD [resident] .in chair /c [with] times of Anxiety .This nurse administered Haldol [antipsychotic medication given to treat certain types of mental disorders] 2 mg [milligram] IM [Intramuscular] shot per NP [Nurse Practitioner] D/T [due to] [increase] agitation & anxiety . Review of the Physician Orders dated 7/1/2024 revealed, .One time dose of Haldol 2 mg [milligram] IM [intramuscular] .Anxiety/Agitation . Review of the Nurse's Notes for Resident #41 dated 7/2/2024 revealed, .Rsd noted to have increased anxiety .Psych NP [Nurse Practitioner] in for visit, family at bedside order received to send Rsd to ER [emergency room ] for eval . Review of the History and Physical for Resident #41 dated 7/2/2024 revealed, .Patient .present [to] emergency room secondary to altered mental status with acting out .family states that yesterday he was able to recognize them and today when she [family member] went to see him he was just very confused in talking out of his head .Was also very agitated .Patient is currently at skilled nursing facility .Patient not able to give any information .per family [he] had not slept in his last 3 days .admitted to the hospital for altered mental status with behavioral issues . Review of the readmission orders for Resident #41 dated 7/8/2024, revealed resident was placed on Seroquel [antipsychotic medication given to regulate mood and behaviors] upon readmission. No PASSAR was updated prior to readmission to reflect the increase behaviors, anxiety, altered mental status, or the use of an antipsychotic. During an interview on 7/16/2024 at 8:36 AM, Resident #41 stated, .I was in [Named Hospital #1] in a special ward . During an interview on 7/18/2024 at 11:50 AM, House Supervisor stated, .a PASARR should be updated if a new psych [psychiatric] diagnosis was given . The House Supervisor was asked when Resident #41 was placed on a prn Antipsychotic and discharged to the hospital due to behaviors was a new PASARR completed? The House Supervisor stated, .I don't have a new PASARR on [Named Resident #41] .It needs to be updated . Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses which included Acquired absence of left leg above knee, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #47 received an antianxiety medication over the last 7 days. Review of the PASARR for Resident #47 dated 3/20/2024 revealed .No mental health diagnosis is known or suspected .Mental Health Symptoms .None or No symptoms experienced .PSYCHOTROPIC MEDICATIONS 1. Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months .No . Level I Outcome .No Level II Condition-Level I Negative . Review of the admission orders dated 3/22/2024 revealed, .ALPRAZOLAM [Antianxiety medication given for Anxiety] .0.25 MG ORAL TWICE DAILY AS NEEDED INDICATION: anxiety . Review of the March 2024 Medication Administration Record (MAR) for Resident #47 revealed Alprazolam 0.25 mg tablet was administered on 3/24/2024, 3/27/2024, 3/28/2024, 3/29/2024, 3/30/2024, and 3/31/2024. Review of the PASARR for Resident #47 dated 4/18/2024 revealed, .No mental health diagnosis is known or suspected .Mental Health Symptoms .None or No Symptoms experienced .PSYCHOTROPIC MEDICATIONS 1. Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months .No . Level I Outcome .No Level II Condition-Level I Negative . The PASARR for Resident #47 dated 3/20/2024 and 4/18/2024 did not reflect the diagnosis of Anxiety or the use of a psychotropic (Alprazolam) medication. Review of the 4/2024 MAR for Resident #47 revealed Alprazolam 0.25 mg a tablet was administered on 4/4/2024, 4/5/2024, and 4/6/2024. Review of the 5/2024 MAR for Resident #47 revealed Alprazolam 0.25 mg tablet was administered on 5/4/2024 and 5/5/2024. During an interview on 7/18/2024 at 11:52 AM, the House Supervisor was asked about Resident #47's PASARR determination and the use of Alprazolam for Anxiety. The House Supervisor stated, .the Anxiety should be reflected on the form .

Based on facility policy review, medical record review, and interviews the facility failed to provide evaluation and rational for continued use of a PRN (as needed) anti-anxiety medication for 1 resident (Resident #47) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, dated 12/2023 revealed, .Residents of the facility who are prescribed a psychotropic medication will be monitored. The resident ' s need for the psychotropic medication will be monitored .Both the medical staff and nursing shall evaluate the effectiveness of PRN orders for psychotropic drugs to manage behavior . Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses which included Acquired absence of left leg above knee, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #47 received an antianxiety over the last 7 days. Review of the admission orders dated 3/22/2024 revealed an order for Alprazolam (psychotropic medication given for anxiety) 0.25 mg (milligram) orally twice daily as needed for anxiety with no stop date. Review of a Pharmacy recommendation dated 3/22/2024 revealed, .PRN Alprazolam-If continued beyond 14 days, complete CMS [Centers for Medicare & Medicaid Services] required review. Please add a stop date to the order . Review of the Medication Administration Record (MAR) for Resident #47 dated 3/2024 revealed Alprazolam 0.25 mg tablet was administered on 3/24/2024, 3/27/2024, 3/28/2024, 3/29/2024, 3/30/2024, and 3/31/2024. Review of the MAR for Resident #47 dated 4/2024 revealed Alprazolam 0.25 mg tablet was administered on 4/4/2024, 4/5/2024, and 4/6/2024. Review of the physician orders dated 4/7/2024 revealed a clarification order for Alprazolam 0.25 mg tablet by mouth twice daily PRN for anxiety x [times] 30 days, then re-eval [re-evaluation]. Review of the MAR for Resident #47 dated 5/2024 revealed Alprazolam 0.25 mg tablet was administered on 5/4/2024 and 5/5/2024. Review of the physician orders dated 5/13/2024 revealed an order to continue Alprazolam 0.25 mg tablet by mouth twice daily as needed x [times] 30 days for anxiety. Review of the Medical Director and Nurse Practitioner (NP) notes from 3/24/2024 to 5/21/2024 revealed no documentation related to the continued need for the use of PRN antianxiety. During an interview on 7/17/2024 at 10:45 AM, the Director of Nursing (DON) stated, .I do know [Resident #47] was on an antianxiety. I am not sure why it doesn ' t have a stop date . During a telephone interview on 7/17/2024 at 4:46 PM, the Pharmacist stated, .I did make the recommendation to add a stop date to the order for the Alprazolam .prn psychotropics should only be given for 14 days and then the MD or NP would need to reevaluate and note the need to continue the medication . During a telephone interview on 7/18/2024 at 10:00 AM, the NP stated, .anyone placed on a prn psychotropic should have a 14 day stop date and then the patient should be reevaluated for the continued need for the medication .

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 53 rooms observed. The facility failed to provide clean equipment for 1 of 53 (Resident #155) sampled residents reviewed. The findings include: Review of the facility policy titled, Disinfection of Bedpans and Urinals, dated 1/16/2024, revealed .Bedpans and urinals are handled in a manner to prevent the spread of infection through personal equipment .Bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge .Store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag or as per facility policy . Review of the facility's policy titled, Guidelines for the Administering and Storage of Oxygen, revised 10/2023, revealed .Oxygen is administered for adults through an oxygen mask or nasal prongs and tubing .The tubing should be kept off the floor .Long periods of non-use O2 [oxygen] tubing will be kept in plastic bag . Observation in a shared bathroom for room [ROOM NUMBER] and 231 on 7/15/2024 at 11:15 AM, revealed an uncovered bedpan sitting in the floor with no name on it. During an interview on 7/15/2024 at 11:30 AM, Licensed Practical Nurse (LPN) G confirmed there was an uncovered bedpan in the bathroom floor between room [ROOM NUMBER] and 231 with no name on it. LPN G stated the bedpan should have been in a bag with the resident's name and room number on it. During an interview on 7/15/2024 at 11:45 AM, the House Supervisor confirmed the uncovered bedpan sitting in the floor in the shared bathroom between room [ROOM NUMBER] and 231 should have been in a bag with the name and room number on it. The House Supervisor stated she did not know why the bedpan was in the floor uncovered, but it would be an infection control issue. Observation in a shared bathroom for room [ROOM NUMBER] and 110 on 7/11/2024 at 11:50 AM, revealed a urine hat [collection device which aids in measuring or collecting urine for a specimen] sitting unbagged on the back of the commode with the initials GM. Review of the resident census revealed no residents with the initials GM in room [ROOM NUMBER] or 110. During observation and interview in the shared bathroom for room [ROOM NUMBER] and 110 on 7/11/2024 at 11:52 AM, the House Supervisor stated, .I don't know who that belongs to [referring to the urine hat], it should be in a bag . ____________________________________________________________________________________ Review of the medical record revealed Resident #155 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease (CKD), unspecified Stage 3. Review of the Care Plan for Resident #155 dated 4/9/2024, revealed a plan and interventions for .POTENTIAL FOR COMPLICATIONS FROM CARDIO-PULMNARY ISSUES: DIASTOLIC CHF [Congestive Heart Failure] AND COPD .ADMINISTOR OXYGEN [O2] PER ORDERS O2 2L [Liters] PNC [per nasal canula - a thin tube to administer oxygen] . Review of Admission Physican Orders for Resident #155 dated 7/8/2024, revealed, .OXYGEN AT 2 L/MIN [liters per minute] PER NC [nasal cannula] OR MASK .PRN [as needed] .CHANGE O2 TUBING PRN FOR LEAKAGE/SOILING. PLACE IN BAG WHEN NOT IN USE .DUONEB [combination of medications Ipratropium bromide/albuterol for inhalation therapy] inh [inhalation] 3 ML [milliliter] inhale 3 ML QID [four times a day] PRN . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #155 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Observation in Resident #155's Room on 7/16/2024 at 8:47 AM, revealed oxygen tubing with nasal cannula lying on the floor next to Resident #155's bed connected to the Oxygen concentrator. During an interview in Resident #155's Room on 7/16/2024 at 8:48 AM, Certified Nursing Assistant (CNA) I confirmed that the oxygen tubing with nasal cannula for Resident #155 was lying on the floor connected to the Oxygen concentrator next to the bed. CNA I stated the Oxygen tubing with nasal cannula should have been placed in the bag connected to the Oxygen concentrator when not in use. During an interview in Resident #155's Room on 7/16/2024 at 8:51 AM, LPN J confirmed Resident #155's Oxygen tubing with nasal cannula was on the floor in front of the Oxygen concentrator next to the bed. LPN J stated Resident #155 was on 2 liters Oxygen PRN and wears it mostly at night. LPN J confirmed the O2 tubing should be kept in the plastic bag on the side of the Oxygen concentrator when not in use. LPN J was asked what risk does Oxygen tubing with nasal cannula on the floor pose to Resident #155. LPN J stated, It is a risk for germs and infection if the Oxygen tubing is on the floor.

Based on facility documentation review, observation and interview, the facility failed to store food in a safe and sanitary manner as evidenced by unlabeled, undated and expired food in the walk-in refrigerator, walk-in freezer and the kitchen dry bin. The Findings include: Facility document review, Untitled, Dated ,[DATE], revealed .all food items are monitored for expiration dates and discarded when they expire . Observation and interview on [DATE] at 9:00 AM with the Dietary Manager in the freezer confirmed 4 large bags of creamed corn expired [DATE], ½ bag of zucchini unlabeled and undated; 4 bags (2 lb) fried green tomatoes undated; 1 bag french style bread unlabeled and undated and 1 partially used bag of garlic knots unlabeled and undated. Continued interview in the Walk-In Refrigerator confirmed 1 container of chicken salad (5 lb) opened and undated. Observation and interview on [DATE] at 4:45 PM in the kitchen with the Dietary Manager confirmed the following in the dry storage bin: 1 partially used bag of cornmeal expired on [DATE]; 8 bags of cornmeal (5lb) expired on [DATE] and 1 bag of flour (5lb) expired on [DATE].

wBased on medical record review, facility documentation review and interview, the facility failed to complete a Quarterly (once every 3 months) Minimum Data Set (MDS) assessment for 20 (#2, #5, #7, #9, #11, #12, #13, #14, #17, #20, #21, #74, #76, #124, #126, #224, #225, #230, #231 and #276) of 40 resident Quarterly assessments reviewed. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #2's Quarterly MDS assessment was due on 11/7/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #2 on 11/7/2019. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #5's Quarterly MDS assessment was due on 12/23/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #5 on 12/23/2019. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #7's Quarterly MDS assessment was due on 12/3/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #7 on 12/3/2019. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #9's Quarterly MDS assessment was due on 11/12/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #9 on 11/12/2019. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #11's Quarterly MDS assessment was due on 12/27/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #11 on 12/27/2019. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #12's Quarterly MDS assessment was due on 12/15/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #12 on 12/15/2019. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #13's Quarterly MDS assessment was due on 12/21/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #13 on 12/21/2019. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #14's Quarterly MDS assessment was due on 11/28/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #14 on 11/28/2019. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #17's Quarterly MDS assessment was due on 12/3/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #17 on 12/3/2019. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #20's Quarterly MDS assessment was due on 11/10/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #20 on 11/10/2019. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #21's Quarterly MDS assessment was due on 12/3/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #21 on 12/3/2019. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #74's Quarterly MDS assessment was due on 12/10/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #74 on 12/10/2019. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #76's Quarterly MDS assessment was due on 11/14/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #76 on 11/14/2019. Medical record review revealed Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #124's Quarterly MDS assessment was due on 12/3/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #124 on 12/3/2019. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #126's Quarterly MDS assessment was due on 12/3/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #126 on 12/3/2019. Medical record review revealed Resident #224 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #224's Quarterly MDS assessment was due on 11/25/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #224 on 11/25/2019. Medical record review revealed Resident #225 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #225's Quarterly MDS assessment was due on 11/25/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #225 on 11/25/2019. Medical record review revealed Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #230's Quarterly MDS assessment was due on 11/7/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #230 on 11/7/2019. Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #231's Quarterly MDS assessment was due on 12/14/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #231 on 12/14/2019. Medical record review revealed Resident #276 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #276's Quarterly MDS assessment was due on 12/24/2019 and was not completed. Medical record review revealed no Quarterly MDS assessment was completed for Resident #276 on 12/24/2019. Interview with the MDS Coordinator on 1/14/2020 at 4:45 PM in the MDS office confirmed no Quarterly MDS assessments had been completed for Residents #2, #5, #7, #9, #11, #12, #13, #14, #17, #20, #21, #74, #76, #124, #126, #224, #225, #230, #231 and #276.

Based on facility policy review, medical record review, observation and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of infection for 4 (#10, #18, #230 and #275) of 6 residents during the noon meal on 1/13/2020. The findings include: Facility policy review, Infection Control Policy, undated, revealed .the facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment. The infection control program is designed to help prevent development and transmission of disease and infection . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with meal set up. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed the resident was independent with meal set up. Medical record review revealed Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #230's Annual MDS assessment dated [DATE] revealed the resident required extensive assistance of one person with meals. Medical record review revealed Resident #275 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #275's Admission MDS dated [DATE] revealed the resident was independent with meal set up. Observation on 1/13/2020 at 12:43 PM revealed Certified Nurse Assistant (CNA) #1 removed a meal tray from the ABCD meal cart, took it into Resident #275's room and sat it on the over bed table. Further observation revealed CNA #1 removed the lid from the tray and then she stated this is not your tray. Further observation revealed CNA #1 brought the meal tray out of Resident #275's room and placed it into the ABCD meal cart. Further observation of the ABCD meal cart revealed 3 other resident trays on the cart. Observation on 1/13/2020 at 12:45 PM revealed CNA #1 pushed the ABCD meal cart to D hall and took out the meal tray she had previously taken into Resident #275's room; took it into Resident #10's room, placed it on the over bed table and set the tray up for the resident to eat. Further observation revealed CNA #1 delivered the other two meal trays on the ABCD meal cart to Resident #18 and Resident #230. Interview with CNA #1 on 1/13/2020 at 1:59 PM in the main dining room confirmed she took the wrong tray into Resident #275's room; sat the tray on the over bed table then brought the tray out of the resident's room and placed it on the meal cart. Continued interview revealed she then delivered the tray to Resident #10 and sat it up. Further interview revealed there were 2 other meal trays on the meal cart and she delivered them to the Resident #18 and #230. Further interview confirmed she was to take the tray back to the dietary department and ask for a new tray for both residents to prevent cross contamination. Interview with Registered Nurse (RN) #2 on 1/14/2020 at 10:25 AM in the common area confirmed staff were not to put a dirty tray back on the meal cart with clean trays. Further interview confirmed when staff take the wrong tray into a residents room they were to get new trays for the residents from the dietary department.

Based on facility policy review, facility documentation review and interview, the facility failed to have 8 hours of Registered Nurse (RN) coverage on 11/10/2019 for 1 of 73 days reviewed. The findings include: Review of the undated facility policy, RN Coverage revealed .This centers recognizes CMS (Centers for Medicare Services) requiring RNs 7 days a week and has stringently attempted to maintain that standard . Facility documentation review of the daily staffing census dated 11/10/2019 revealed the RN worked 4 regular hours. Facility documentation review of the nursing staff time punches dated 11/10/2019 revealed the RN worked 6 regular hours. Interview with the Assistant Director of Nursing (ADON) also known as the scheduler on 1/15/2020 at 1:35 PM in the conference room confirmed the facility had RN coverage for 6 hours on 11/10/2019. Interview with the Administrator on 1/15/2020 at 6:04 PM in the conference room confirmed there were not any RN's to cover the 8 hours on (MONTH) 10th.

Based on medical record review and interviews, the facility failed to develop a comprehensive care plan for 1 ( #274)of 40 residents reviewed. The findings include: Medical record review revealed Resident #274 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #274 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Medical record review revealed no comprehensive care plan was developed for Resident #274. Interview with the Assistant Director of Nursing (ADON) on 1/15/2020 at 1:35 PM in the conference room revealed the floor nurses were responsible for completion of the interim care plan and the the MDS coordinator was responsible for completion of the comprehensive care plans. Interview with the MDS Coordinator on 1/15/2020 at 1:52 PM in the MDS office confirmed Resident #274 did not have a comprehensive care plan completed. Interview with the Director of Nursing (DON) on 1/15/2020 at 5:19 PM in the conference room confirmed the care plans should be done quarterly. (named Resident #274) should have had a comprehensive care plan.

Based on medical record review, facility documentation review and interview, the facility failed to complete an Annual Minimum Data Set (MDS) assessment for 1 (#125) of 40 resident assessments reviewed. The findings include: Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Facility document review revealed Resident #125's Annual MDS assessment was due on 12/15/2019 and was not completed. Medical record review revealed no Annual MDS assessment completed for Resident #125 on 12/15/2019. Interview with the MDS Coordinator on 1/14/2020 at 4:45 PM in the MDS office confirmed no Annual MDS assessment had been completed for Resident #125.

Based on facility policy review, medical record review, observation and interview, the facility failed to treat 1 (#229) of 1 resident who required a urinary catheter with dignity related to not covering the resident's catheter drainage bag. The findings include: Review of the facility policy, Resident Rights Policy dated 12/2019, revealed .The resident has the right to a dignified existence, self- determination, and communication with access to persons and services inside and outside the facility . Medical record review revealed Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #229 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Continued review revealed Resident #229 required an indwelling catheter. Medical record review of Resident #229's physician orders dated 1/1/2020, revealed .Catheter care every shift . Medical record review of Resident #229's care plan dated 1/29/2019, revealed .admitted with indwelling catheter for bladder elimination due to [MEDICAL CONDITION] .Keep catheter bag covered and tubing secured to prevent pulling and urethral trauma . Observation on 1/13/2020 at 12:09 PM revealed Resident #229 sitting in the dining room with his urinary catheter uncovered, in view and attached to his wheelchair. Observation on 1/13/2020 at 5:44 PM in the day area revealed Resident #229 seated in his wheelchair with his catheter bag in view and uncovered. Observation and interview with Certified Nurse Aide (CNA) #4 on 1/13/2020 at 12:34 PM in the dining room revealed Resident #229 without a dignity bag covering his catheter bag. Continued interview CNA #4 stated .I know it's (catheter drainage bag) supposed to have a cover . Interview with Licensed Practical Nurse (LPN) #1 on 1/13/2020 at 6:00 PM in day area confirmed Resident #229 did not have a dignity bag covering his catheter drainage bag. Interview with the Director of Nursing (DON) on 1/15/2020 at 5:19 PM in the conference room confirmed the facility was responsible for covering catheter drainage bags. Interview with the Administrator on 1/15/2020 at 6:04 PM in the conference room confirmed there are bag covers in the room to promote dignity and would be the appropriate way to do it.

Based on policy review, employee record review, medical record review, observation and interview, the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each residents. The facility Administrator's failure to thoroughly investigate falls, failure to implement a fall intervention of monitoring the functionality of alarms, the facility's utilization of unsupervised noncertified Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) providing direct resident care, the failure to ensure staff had an accurate job description, reference verification, competency, and abuse registry verification and the failure to ensure staffing was providing the required assistance to residents and were supervised placed 2 residents (#1 and #2) of 9 residents reviewed with falls in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident); the Administrator failed to ensure staff reported an allegation of abuse to administration for investigation and failed to prevent Abuse for 1 (#5) of 13 residents reviewed. The facility's noncompliance resulted in a fall for Resident #1, the fall resulted in a laceration to the head requiring 10 sutures. The facility's noncompliance resulted in a fall for Resident #2 due to 3 different facility staff leaving Resident #2 unattended in the bathroom on 3 separate occasions. The fall resulted in a [MEDICAL CONDITION]. A partial-extended survey was conducted on 9/10/19 - 9/19/19. The Administrator and facility owner were notified of the Immediate Jeopardy on 9/18/19 at 5:10 PM in the conference room. The Immediate Jeopardy was effective from 6/3/19 through 9/19/19. F689, F728, and F835 was cited at a scope and severity of K. The facility's noncompliance resulted in psychosocial Harm to Resident #5. F600 was cited as a scope and severity of [NAME] An acceptable Allegation of Compliance (A[NAME]) which removed the immediacy of the jeopardy was received on 9/19/19 at 5:10 PM and the corrective actions were validated onsite through observation, interviews and document review. Noncompliance for F689, F728, and F835 continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. Substandard Quality of Care was cited at F689. The findings include: The facility did not have job descriptions for the Administrator, hired on 7/1/19, and the Director of Nursing (DON), hired on 1/2/18. 1. Review of the undated facility policy, Abuse, Neglect, Misappropriation of Property & (and) Exploitation, revealed .Definitions: Abuse - the willful infliction of injury .intimidation, pain or mental anguish .Each Resident .has the right to be free from mistreatment .Identification: identify events, such as suspicious bruising .occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation .It is the responsibility of the staff .to prohibit and prevent any Resident from Abuse . Reporting Abuse .If ABUSE is suspected, of any type, employees are required to immediately notify the charge nurse on their unit where the ABUSE is suspected to have occurred. The charge nurse, whatever shift, is then to notify the social worker or the director of nursing immediately, who will then notify the administrator . The facility failed to identify and prevent abuse for 1 resident. The facility staff failed to implement the facility abuse protocol to inform the administration of an allegation of abuse. Interview with the Social Worker, who was also the Abuse Coordinator, on 8/13/19 at 3:25 PM in the Social Worker's office, confirmed the facility staff failed to report the allegation of abuse immediately to the DON or the Social Worker per facility policy. Interview with the DON on 8/13/19 at 4:18 PM in the conference room revealed the facility did not substantiate the incident as abuse because the resident .said she was okay . Refer to F600 and F607. 2. The facility failed to implement the staff monitoring of any resident with an alarm for the proper placement and functionality of the alarm in order to prevent a fall. Resident #1 fell resulting in a laceration requiring 10 sutures. The facility failed to provide the extensive assistance and supervision, by 3 staff members on 3 separate occasions, to Resident #2 which resulted in a fall and a fracture. The facility failed to thoroughly investigate falls. The facility failed to ensure staff was competent to perform the duties required and failed to supervise staff. The facility utilization of unsupervised noncertified Nurse Aides providing direct resident care. Interview with the Administrator, DON, and ADON on 8/13/19 at 1:50 PM in the conference room confirmed the facility failed to monitor the alarm functionality, failed to interview staff and witnesses, failed to have specific information regarding the fall, and failed to determine the root cause of the fall, resulting in a non-thorough investigation. Interview with the DON and ADON on 9/11/19 at 4:30 PM in the conference room confirmed at times the facility did not obtain orders for the alarms. Interview with the DON and ADON on 9/12/19 at 2:05 PM in the conference room confirmed the facility had unsupervised noncertified NAs assigned to residents. Further interview confirmed 3 staff members (RN #1, LPN #1 and NA #1) had left a resident unattended in the bathroom at 3 separate times; therefore the facility failed to provide the supervision of staff and the required assistance to the resident. Interview with the DON and ADON on 9/12/19 at 2:55 PM in the conference room confirmed the facility failed to ensure alarms were turned on in order to alert the staff. Refer to F656 and F689. 3. Review of the undated facility Nurse Aide job description/Job position found in the employee files revealed .Major duties and responsibilities .Assist residents with dental and mouth care .assist with feeding of the residents .Perform after meal care .bathe residents as assigned in accordance with our established nursing care procedures .dress residents .comb and brush hair .Qualifications .must obtain State certification within 120 days of being employed . Review of employee files revealed the facility hired and utilized noncertified Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) and provided them a job description specifying the provision of direct resident care; and did not specify the need for supervision. Further review revealed the facility failed to verify the competencies for 11 (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, and #12); failed to obtain the abuse registry verification for 4 (#1, #2, #8, #9); and failed to verify references for 8 (#1, #2, #3, #7, #8, #9, #10, #12) of 11 employee records reviewed. Interview with the Administrator and the Director of Nursing (DON) on 8/7/19 at 9:03 AM in the conference room when asked what duties the facility expected the NAs to perform, the DON revealed, .my intent was to do more than just stand around but to provide assistance .They were supposed to be supervised . When asked if the NAs had been reviewed for competencies the DON revealed she .would need to check . When the DON was asked when 1 to 2 NAs were scheduled on a unit with a nurse did she expect the NAs to perform direct care and the DON would not respond. Interview with the DON on 8/13/19 at 4:18 PM in the conference room confirmed the NA's did not have competency verification. Interview with the Administrator, DON, ADON, and the Business Office Manager on 8/14/19 at 5:05 PM in the conference room, when asked why the job descriptions in the NA files included direct patient care responsibilities, the DON, ADON, and the Administrator did not respond. Interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Business Office Manager on 8/15/19 at 4:00 PM in the conference room, when asked if the employees were required to have abuse registry verification and reference verification prior to having resident contact, the Administrator confirmed all staff were to have abuse and reference verification before any patient contact. Refer to F728. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed on 9/19/19 through review of the facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. The facility had eliminated 3 of the 4 remaining noncertified Nurse Aides by 9/12/19. The one remaining noncertified Nurse Aide, NA #7, was removed from the nursing department to the activities department until the NA successfully completed the certification program and test. The facility/governing body implemented a new policy to not hire nurse aides effective 9/19/19. The facility revised policies addressing noncertified nurse aides and adequate staffing. The surveyor reviewed the facility policy, Hiring of Non-certified Nursing Aides. The review confirmed the policy was effective on 9/19/19 and the facility would not hire nor schedule any noncertified nurse aides. The surveyor reviewed the facility policy, Sufficient Staffing. The review confirmed the policy was effective on 9/19/19. Further review confirmed the Administrator and the ADON/Scheduler were to review to ensure adequate staff were scheduled twice weekly. The Administrator would utilize a spreadsheet to determine staffing per unit. The surveyor reviewed the weekly staffing report dated 9/19/19 - 9/22/19. The review confirmed the Administrator and Assistant Director of Nursing/Scheduler had reviewed the staffing on 9/17/19. The surveyor reviewed the 9/2019 nursing schedule. The review confirmed the 1 remaining noncertified nurse aide (NA #7) had not been scheduled in the nursing department since 9/1/19 and was scheduled in activities on Saturdays. Telephone interview with NA #7 on 9/11/19 at 9:57 AM confirmed the NA had no resident contact since 9/1/19 and was changed to the activities department until the certification test was successfully completed. The surveyor interviewed the Administrator, on 9/19/19 at 4:18 PM, who confirmed on 9/17/19 the Administrator and the Assistant Director of Nursing had checked the staffing for 9/19/19 through 9/22/19. Further interview confirmed the staffing was discussed at every morning meeting and reviewed for sufficiency and coverage. The staffing was based on the acuity of the residents. Further interview revealed if there were any staff shortages identified in the staffing report, current staff would be given the opportunity to provide coverage and/or the licensed staff in administration would cover the shortage. Further interview confirmed 3 noncertified nurse aides were no longer employed by the facility and the remaining NA would work in the activities department until the NA successfully completed the certification course and passed the test. Further interview confirmed all other staff were certified nurse aides or licensed nurses and no noncertified nurse aides would be hired. 2. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Charge Nurse to report accident to the DON (ADON, MDS Coordinator or Administrator when DON not available) to ensure the fall the revised Fall Investigation packet was initiated and an intervention was put into place. The facility utilized the current Falls Risk policy. The surveyor reviewed the revised fall investigation packet. The falls investigation packet confirmed a Falls Management Program policy was implemented 7/29/19, a revised fall investigation form, a revised Incident/Accident report, a revised witness statement, and a revised neuro check form. The surveyor review of the Falls Risk policy confirmed the Charge Nurse would initiate the investigation packet, initiate an intervention and verbally notify the DON/designee immediately. The surveyor interviewed 2 LPNs, 3 CNAs and 2 dietary staff on duty on 9/19/19. The interviews confirmed the staff was knowledgeable of the reporting of falls and the duties of the charge nurse and the initiation of the intervention. Further interview with the licensed nurses confirmed the facility had in-serviced on the new fall packet, the new fall investigation forms, and the immediate notification of the DON. The surveyor review of the in-service post test addressing falls confirmed the facility had initiated the in-service training. 3. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Attending Physician/Nurse Practitioner will be immediately notified of the fall, regardless of severity of the injury, and the intervention. The surveyor reviewed the revised fall investigation packet. The review confirmed the falls investigation packet included a Falls Management Program policy implemented 7/29/19 and the Charge Nurse would immediately notify the physician/nurse practitioner regardless of the severity of the injury. The surveyor review of the in-service post test addressing falls confirmed the facility had initiated the in-service training. The surveyor telephone interview with the Medical Director on 9/16/19 at 1:33 PM confirmed the Medical Director/Nurse Practitioner were to be notified of falls regardless of the severity of the injury. The surveyor interviewed all nursing staff on duty on 9/19/19. The interviews confirmed the staff was knowledgeable of the reporting of falls, duties of the charge nurse and the immediate notification of the physician/nurse practitioner regardless of the injury severity. 4. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Falls Committee would investigate fall incidents the following business day to determine the root cause and develop appropriate intervention, in the event the fall occurred on Friday after business hours through beginning of business Monday, the DON/designee would determine the root cause and immediate intervention. The surveyor review of the 9/2019 Incident/Accident Analysis Log confirmed the facility had no falls after 9/17/19. Interview with the DON on 9/19/19 at 3:00 PM and review of the 3 falls on and prior to 9/17/19 confirmed the facility Falls Committee had met timely to determine the root cause and intervention. 5. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the adaptation and the utilization of the revised Post Fall Investigation by the Falls Management Committee. The surveyor review of the revised fall investigation packet confirmed a revised Post Fall Investigation form. The surveyor interviewed all nursing staff on 9/19/19. The interviews confirmed the staff was knowledgeable of the revised Post Fall Investigation form. The surveyor interview of the members of the Falls Management Committee, DON, ADON, MDS Coordinator, on 9/19/19 at 3:00 PM confirmed the committee met the business day after the fall to review the fall information and complete the revised Post Fall Investigation form. The committee would meet to determine the root cause and appropriate intervention. 6. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the discontinuation of the alarms and initiation of intervention; updating of the comprehensive and CNA care plan regarding alarm and intervention. The surveyor observed the Falls Management Committee/Interdisciplinary Team meeting on 9/19/19 to discuss the ordered discontinuation of the alarms and the determination of the new intervention. The surveyor observation of the residents on 9/19/19 confirmed the ordered removal of alarms had been completed and the new intervention was in place, and all alarms were removed from the supply storage areas to ensure inaccessibility. The surveyor review of the medical records, of all residents identified with an alarm, confirmed a physician order [REDACTED]. 7. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: direct care staff education initiated 9/18/19 on the 11:00 PM-7:00 AM shift and ongoing, education of staff not on duty to be completed before scheduled shift, and education of new hired staff during orientation. The surveyor review of the in-service training records confirmed staff, of all departments, were receiving education on reporting of falls, duties of the charge nurse, the fall investigation packet contents, interventions and the updating of the comprehensive and CNA care plans. Further review confirmed the staff scheduled on 9/18/19 on the 11:00 PM - 7:00 AM had been in-serviced on the revised falls protocols. The surveyor interviews with all nursing and dietary staff on duty 9/19/19 confirmed the staff was knowledgeable of the reporting of falls, duties of the charge nurse, the revised fall investigation packet contents, interventions and care plan. The surveyor interview with the Administrator, on 9/19/19 at 4:18 PM in the conference room, confirmed any new hired staff member would be educated on the revised fall protocol upon orientation and staff not on duty would receive in-service training before the scheduled shift. Noncompliance for F835 continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of job description, interview, facility investigation documentation review, facility staffing documentation review and employee record review, the facility failed to ensure full-time employees working as Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) were either in a State approved training and competency evaluation program or had recently successfully completed such a program for 11 NA employees (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12) of 11 NA hired by the facility. This failure had the potential to result in negative outcomes for the 44 residents residing in the facility at the time of the survey, including 6 residents (#1, #2, #5, #8, #10, #13) of 13 residents reviewed. The facility's noncompliance for Resident #1 resulted in a fall and a laceration to the head requiring 10 sutures. The facility's noncompliance for Resident #2 resulted in a fall and a [MEDICAL CONDITION]. The facility's noncompliance for Resident #5 resulted in abuse by facility staff. The facility's noncompliance for Residents #8, #9, #10 and #13 resulted in falls. The facility's failure placed Resident #1 and Resident #2 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure placed Resident #5 in Actual Harm for Abuse. The Administrator and facility owner were notified of the Immediate Jeopardy on 9/18/19 at 5:10 PM in the Conference Room. An acceptable Allegation of Compliance was received on 9/19/19 at 5:10 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observation and staff interviews conducted on site on 9/19/19. The Immediate Jeopardy was effective from 6/3/19 - 9/19/19. Noncompliance continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. F689 is Substandard Quality of Care. The findings include: Review of the undated facility job description for the Job Position/Description Nursing Assistant (NA) revealed .Major Duties and Responsibilities .Assist residents with dental and mouth care .Assist with .feeding of resident .Perform after meal care as required (i.e. cleaning resident's hands, face, clothing, etc.) .Assist in preparing residents for meal (i.e. taking to/from dining room .assisting with feeding .supervision in dining rooms, etc.) .bathe residents as assigned and in accordance with our established nursing care procedures .Dress residents neatly .Assist residents in dressing as necessary .Comb and brush resident's hair daily and as needed. Shampoo as instructed .Qualifications .must obtain State certification within 120 days of being employed . Review of the 11 NA employee records for hire date, date began working as a NA, first date providing direct resident care and nursing aide job description verification revealed the following: NA #1 was hired as a NA on 6/8/19 and began providing direct resident care on 6/8/19. The job description was signed by the NA on 6/9/19. Resident #2's fall resulted in a fracture on 7/14/19 with NA #1 and Licensed Practical Nurse (LPN) #1 assigned to the resident. LPN #1, NA #1 and Registered Nurse (RN) #1 all left the resident unattended in the bathroom on 3 separate occasions on 7/14/19. Refer to F 689. NA #2 was hired as a NA on 3/26/19 and began providing direct resident care on 3/27/19. The NA's employee record did not contain a job description. Resident #1 fell on [DATE] at 9:00 PM and was assigned to NA #2 who transferred the resident into the bed. The bed pad alarm was not working properly at the time of the fall. LPN #6 was assigned to the resident at the time of the fall with NA #6 in orientation on the unit on 6/3/19. Resident #1 fell on [DATE] resulted in a laceration requiring 10 sutures was assigned to NA #2. The NA transferred the resident into the bed and the bed pad alarm was not working properly at the time of the fall. RN #1 and NA #7 were also on the unit with a total of 26 residents. Refer to F689. Resident #5's psychosocial abuse occurred on 6/13/19 by NA #3, with NA #2 and CNA #6 present and witnessing NA #3 splashing water in the resident's face purposely. NA #2 and CNA #6 left NA #3 alone with the resident. Refer to F600. Resident #10 fell on [DATE] and was assigned to NA #2 and LPN #7. NA #12 was also on the unit with a total of 25 residents. Refer to F689. NA #3 was hired as a NA on 6/22/18 and signed the job description on 6/22/18. NA #3 was terminated on 6/13/19. Resident #5's psychosocial abuse occurred on 6/13/19 by NA #3 who purposely splashed water into the resident's face. NA #2 and CNA #6 were present to witness NA #3's actions. NA #2 and CNA #6 left NA #3 alone with the resident. Refer to F600. NA #4 was hired as a NA on 12/4/18 and signed the job description on 12/7/18. NA #4 was terminated on 6/12/19. NA #6 was hired as a NA on 5/28/19 and signed the job description on 5/29/19. NA #6 was terminated in (MONTH) 2019. Resident #1 fell on [DATE] at 9:00 PM and was assigned to NA #2 and LPN #6. NA #6 was in orientation on 6/3/19 and worked alone with LPN #3 from 3:00 PM - 6:00 PM with a total of 26 residents. Refer to F689. NA #7 was hired as a NA and began providing direct resident care on 6/4/19. The employee record did not contain a job description. Resident #1 fell on [DATE] resulted in a laceration requiring 10 sutures and was assigned to NA #2 and RN #1. NA #7 was also on the unit with a total of 26 residents. Refer to F689. Resident #8 fell on [DATE] and was assigned to NA #12 and RN #2. NA #7 was also on the unit with a total of 24 residents. RN #1 was alone on the unit from 3:00 PM - 4:30 PM. Refer to F689. NA #8 was hired as a NA and began providing direct resident care on 6/8/19. The job description was signed on 6/8/19. NA #9 began working as a NA on 7/8/19 and began providing direct resident care on 7/8/19. The NA job description was not signed. Resident #13 fell on [DATE] with NA #9, in orientation, on the unit with 25 residents with CNA #9 and LPN #2. Refer to F689. NA #10 began working as a NA on 7/29/19 and began providing direct resident care on 7/29/19. The employee record did not contain a NA job description. NA #11 was hired on 7/3/19 and began working as a NA on 7/7/19. NA #7 began providing direct resident care 7/7/19. The job description was signed on 7/3/19. NA #12 began working as a NA on 6/8/18 and signed the job description on 6/8/18. Resident #8 fell on [DATE] and was assigned to NA #12 and RN #2. NA #7 was also on the unit with a total of 24 residents. RN #2 was alone on the unit from 3:00 PM - 4:30 PM. Refer to F689. Further review of the employee records revealed no competencies were conducted for the NAs. Interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 8/7/19 at 9:03 AM in the conference room when asked what duties the facility expected the NAs to perform, the DON revealed .my intent was to do more than just stand around but to provide assistance . When asked if the NAs were reviewed for competency the DON revealed .would need to check . Interview with Certified Nurse Aide (CNA) #8 on 8/12/19 at 4:40 PM in the conference room when asked if the CNA was aware if the NAs provided residents bathing, showering, incontinence care, transferring, and/or feeding assistance without supervision, the CNA revealed .Yes, I'm aware it happened at times . Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM revealed .Since I was hired I did all the care, sometimes a nurse or CNA was there but I've been on a hall by myself and did the entire patient care by myself . Telephone interview with NA #8 on 9/12/19 at 9:57 AM revealed the NA had repositioned, fed and provided incontinence care to residents without any other staff present. Telephone interview with NA #9 on 8/13/19 at 10:03 AM when asked what the facility told the NA of the duties and responsibilities the NA was to perform, the NA revealed .bathing, changing the resident (incontinence care), walking them, feeding them, dressing them . because we're so understaffed .facility had told us to ask for help and I had asked for help and sometimes they could help me, but I had to do it on my own too . Interview with the DON on 8/13/19 at 4:18 PM in the conference room confirmed the NAs did not have competency verification. Interview with the Administrator, DON, ADON, and Business Office Manager on 8/14/19 at 5:05 PM in the conference room, when asked why the job descriptions in the NAs file included direct patient care responsibilities, the DON, ADON, and Administrator did not respond. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed on 9/19/19 through review of the facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. The facility had eliminated 3 of the 4 remaining noncertified Nurse Aides by 9/12/19. The one remaining noncertified Nurse Aide, NA #7, was removed from the nursing department to the activities department until the NA successfully completed the certification program and test. The facility/governing body implemented a new policy to not hire nurse aides effective 9/19/19. The facility revised policies addressing noncertified nurse aides and adequate staffing. The surveyor reviewed the facility policy, Hiring of Non-certified Nursing Aides. The review confirmed the policy was effective on 9/19/19 and the facility would not hire nor schedule any noncertified nurse aides. The surveyor reviewed the facility policy, Sufficient Staffing. The review confirmed the policy was effective on 9/19/19. Further review confirmed the Administrator and the ADON/Scheduler were to review to ensure adequate staff were scheduled twice weekly. The Administrator would utilize a spreadsheet to determine staffing per unit. The surveyor reviewed the weekly staffing report dated 9/19/19 - 9/22/19. The review confirmed the Administrator and Assistant Director of Nursing/Scheduler had reviewed the staffing on 9/17/19. The surveyor reviewed the 9/2019 nursing schedule. The review confirmed the 1 remaining noncertified nurse aide (NA #7) had not been scheduled in the nursing department since 9/1/19 and was scheduled in activities on Saturdays. Telephone interview with NA #7 on 9/11/19 at 9:57 AM confirmed the NA had no resident contact since 9/1/19 and was changed to the activities department until the certification test was successfully completed. The surveyor interviewed the Administrator, on 9/19/19 at 4:18 PM, who confirmed on 9/17/19 the Administrator and the Assistant Director of Nursing had checked the staffing for 9/19/19 through 9/22/19. Further interview confirmed the staffing was discussed at every morning meeting and reviewed for sufficiency and coverage. The staffing was based on the acuity of the residents. Further interview revealed if there were any staff shortages identified in the staffing report, current staff would be given the opportunity to provide coverage and/or the licensed staff in administration would cover the shortage. Further interview confirmed 3 noncertified nurse aides were no longer employed by the facility and the remaining NA would work in the activities department until the NA successfully completed the certification course and passed the test. Further interview confirmed all other staff were certified nurse aides or licensed nurses and no noncertified nurse aides would be hired. 2. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Charge Nurse to report accident to the DON (ADON, MDS Coordinator or Administrator when DON not available) to ensure the fall the revised Fall Investigation packet was initiated and an intervention was put into place. The facility utilized the current Falls Risk policy. The surveyor reviewed the revised fall investigation packet. The falls investigation packet confirmed a Falls Management Program policy was implemented 7/29/19, a revised fall investigation form, a revised Incident/Accident report, a revised witness statement, and a revised neuro check form. The surveyor review of the Falls Risk policy confirmed the Charge Nurse would initiate the investigation packet, initiate an intervention and verbally notify the DON/designee immediately. The surveyor interviewed 2 LPNs, 3 CNAs and 2 dietary staff on duty on 9/19/19. The interviews confirmed the staff was knowledgeable of the reporting of falls and the duties of the charge nurse and the initiation of the intervention. Further interview with the licensed nurses confirmed the facility had in-serviced on the new fall packet, the new fall investigation forms, and the immediate notification of the DON. The surveyor review of the in-service post test addressing falls confirmed the facility had initiated the in-service training. 3. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Attending Physician/Nurse Practitioner will be immediately notified of the fall, regardless of severity of the injury, and the intervention. The surveyor reviewed the revised fall investigation packet. The review confirmed the falls investigation packet included a Falls Management Program policy implemented 7/29/19 and the Charge Nurse would immediately notify the physician/nurse practitioner regardless of the severity of the injury. The surveyor review of the in-service post test addressing falls confirmed the facility had initiated the in-service training. The surveyor telephone interview with the Medical Director on 9/16/19 at 1:33 PM confirmed the Medical Director/Nurse Practitioner were to be notified of falls regardless of the severity of the injury. The surveyor interviewed all nursing staff on duty on 9/19/19. The interviews confirmed the staff was knowledgeable of the reporting of falls, duties of the charge nurse and the immediate notification of the physician/nurse practitioner regardless of the injury severity. 4. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Falls Committee would investigate fall incidents the following business day to determine the root cause and develop appropriate intervention, in the event the fall occurred on Friday after business hours through beginning of business Monday, the DON/designee would determine the root cause and immediate intervention. The surveyor review of the 9/2019 Incident/Accident Analysis Log confirmed the facility had no falls after 9/17/19. Interview with the DON on 9/19/19 at 3:00 PM and review of the 3 falls on and prior to 9/17/19 confirmed the facility Falls Committee had met timely to determine the root cause and intervention. 5. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the adaptation and the utilization of the revised Post Fall Investigation by the Falls Management Committee. The surveyor review of the revised fall investigation packet confirmed a revised Post Fall Investigation form. The surveyor interviewed all nursing staff on 9/19/19. The interviews confirmed the staff was knowledgeable of the revised Post Fall Investigation form. The surveyor interview of the members of the Falls Management Committee, DON, ADON, MDS Coordinator, on 9/19/19 at 3:00 PM confirmed the committee met the business day after the fall to review the fall information and complete the revised Post Fall Investigation form. The committee would meet to determine the root cause and appropriate intervention. 6. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the discontinuation of the alarms and initiation of intervention; updating of the comprehensive and CNA care plan regarding alarm and intervention. The surveyor observed the Falls Management Committee/Interdisciplinary Team meeting on 9/19/19 to discuss the ordered discontinuation of the alarms and the determination of the new intervention. The surveyor observation of the residents on 9/19/19 confirmed the ordered removal of alarms had been completed and the new intervention was in place, and all alarms were removed from the supply storage areas to ensure inaccessibility. The surveyor review of the medical records, of all residents identified with an alarm, confirmed a physician order [REDACTED]. 7. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: direct care staff education initiated 9/18/19 on the 11:00 PM-7:00 AM shift and ongoing, education of staff not on duty to be completed before scheduled shift, and education of new hired staff during orientation. The surveyor review of the in-service training records confirmed staff, of all departments, were receiving education on reporting of falls, duties of the charge nurse, the fall investigation packet contents, interventions and the updating of the comprehensive and CNA care plans. Further review confirmed the staff scheduled on 9/18/19 on the 11:00 PM - 7:00 AM had been in-serviced on the revised falls protocols. The surveyor interviews with all nursing and dietary staff on duty 9/19/19 confirmed the staff was knowledgeable of the reporting of falls, duties of the charge nurse, the revised fall investigation packet contents, interventions and care plan. The surveyor interview with the Administrator, on 9/19/19 at 4:18 PM in the conference room, confirmed any new hired staff member would be educated on the revised fall protocol upon orientation and staff not on duty would receive in-service training before the scheduled shift. Noncompliance for F728 continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, review of the facility fall investigation, interview and observation, employee record review, the facility failed to investigate falls thoroughly, failed to supervise the Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation), failed to provide staff supervision and failed to provide resident supervision and assistance necessary to prevent a fall for 5 residents (#1 #2, #8, #9 and #13) of 9 residents reviewed for falls. The facility's noncompliance resulted in a fall for Resident #1, the fall resulted in a laceration to the head requiring 10 sutures. The facility's noncompliance resulted in a fall for Resident #2 due to 3 different facility staff leaving Resident #2 unattended in the bathroom on 3 separate occasions. The fall resulted in a [MEDICAL CONDITION]. This failure placed Resident #1 and Resident #2 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and facility owner were notified of the Immediate Jeopardy on 9/18/19 at 5:10 PM in the Conference Room. An acceptable Allegation of Compliance was received on 9/19/19 at 5:10 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observation and staff interviews conducted on site on 9/19/19. The Immediate Jeopardy was effective from 6/3/19 - 9/19/19. Noncompliance continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. F689 is Substandard Quality of Care. The findings include: Review of the undated facility policy, Fall Risk, revealed .All residents are considered to be a fall risk .Implementation: 1. Use Fall Risk Assessment form to identify each resident for risk upon admission/readmission/as needed .Fall Investigation Process .all falls/Incidents will be investigated to determine cause and Possible interventions .Procedure: When a resident has a fall/incident: The Charge Nurse will fill out the appropriate incident packet. The charge nurse will notify the physician of any major injuries (fractures, major bleeding, hematomas, etc.) .The DON (Director of Nursing) or designee will review falls/incidents in the morning meeting Monday thru (through) Friday . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing assessment dated [DATE] revealed Resident #1 had a score of 20 on the Fall Risk Assessment indicating the resident was at high risk for falls. Medical record review of the Admission Physician Orders dated 4/29/19 revealed Resident #1 was to have .Bed pad (pressure) alarm (alarm alerts care giver with audio alarm when the resident gets out of the bed or chair) on bed @ (at) all times for safety, tab alarm (A pull string attached to the secured alarming device and to the resident. When the pull string contact is disrupted the alarm alerts care giver with audio alarm when the resident gets out of the bed or chair) @ all times when up in w/c (wheelchair) for safety .Bed in lowest position @ all times . Review of the facility investigation documentation, written by Licensed Practical Nurse (LPN) #6, dated on 5/1/19 at 7:00 PM revealed Resident #1 was found on the dining room floor with a very small scratch bleeding on right cheek which stopped bleeding immediately after cleansing. Further review of the facility investigation documentation, written by LPN #5, revealed on 5/1/19 at 7:00 PM LPN #5 heard the alarm sounding and noted Resident #1 on floor in a fetal position on the right side in dining room. As a result of the fall the resident had a .very small scratch to R (right) side of face . The new intervention implemented was .continuous supervision while up out of bed, remove from DR (dining room) after meals, at NS (nursing station) . Further review revealed NA #4, Certified Nurse Aide (CNA) #8 and LPN #5 were providing Resident #1 care as nurse aides/certified nurse aides. Telephone interview with NA #4 on 8/13/19 at 9:21 AM revealed .I'm the one that found (named Resident #1) .I was doing rounds, (Resident #1) had alarm but at the time he took it off. Looked like he had slid out of the wheelchair in the dining room .I saw him when he was on the floor .and presented to (nurse). The nurse (LPN #5) checked the resident and we got him in the chair and reattached alarm . Interview with CNA #8 on 8/12/19 at 4:40 PM in the conference room revealed CNA #8 was in the dining room and saw Resident #1 seated in the wheelchair. Further interview revealed the resident .usually sat in the wheelchair after eating for a little bit and .just that quick he was on the floor .I remember resident on the floor and (named LPN #5) checking the resident .he was fine and got resident up into the wheelchair . Review of the fall investigation involving Resident #1 on 5/1/19 revealed no statement from CNA #8 or NA #4. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had moderately impaired hearing and vision with no devices; unclear speech, rarely or never made self understood, and rarely or never understood others. The resident had a score of 3 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The resident had no change in mental status, had exhibited inattentive and disorganized thinking continuously with no fluctuation. The resident required extensive 2+ (or more) person assistance with transferring and required extensive 1 person assistance for bed mobility. Resident #1 required total 1 person assistance for locomotion on/off unit and for toileting. The resident's balance was not steady and required staff assistance for stabilization when moving from a seated to a standing position, when walking, and when doing surface to surface transferring. The resident did not turn around or move self on/off the toilet. The resident had fallen 1 month and 2-6 months prior to admission. The resident had a fall with injury after the admission. The resident had alarms on the bed and the chair daily. Medical record review of the Nurse's Notes, written by LPN #6, for Resident #1 dated 6/3/19 revealed .Called to room by (NA #2), resident laying on floor beside bed, no apparent injury, assisted back to bed, neurochecks all WNL (within normal limits) . Review of the investigation documentation dated 6/3/19 at 9:00 PM revealed the pressure pad alarms were used in the chair and the bed. Further review of the investigation by the interdisciplinary team revealed .check alarm functionality q (every) shift, to ensure proper working order . Telephone interview with LPN #6 on 8/12/19 at 3:30 PM confirmed the LPN was assigned to Resident #1 on 6/3/19 when the fall occurred. Further interview revealed .I .was called to the resident's room by (named NA #2). First she told me she had put the resident in the bed. Later she told me she had left the resident in the wheelchair. From what I saw it looked like the resident had rolled out of the wheelchair. The resident was constantly playing with something down on the floor, leaning over to touch something there or not. Looked like he had rolled forward out of wheelchair onto the floor by way he was on the floor. The back of the wheelchair was against the bed, the resident's feet were in front of the opening of the wheelchair and his head was toward a wall. I don't recall now if the alarm was sounding or not. He had a pad alarm in the chair if I remember right .He was non-compliant with safety measures . Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM confirmed the NA was assigned to Resident #1 on 6/3/19. Further interview revealed .I took (named Resident #1) to his room and put him into the bed by myself .I left the room, went to another resident's room and then heard (named Resident #1) talking. I seen him on the floor and I said 'Why you on the floor?' and he said 'Didn't you hear me yelling for you?' I said 'No' and I got the nurse . Interview with the DON on 8/13/19 at 1:50 PM in the conference room revealed the DON expected the alarm functionality to be monitored every shift and documented on the MAR/TAR (Medication Administration Report/Treatment Administration Report). Further interview revealed . should expect to see functionality checked after the 6/3/19 fall, I hope . Further interview revealed the DON was checking the alarm functionality because .it wasn't working right . Medical record review of the 6/2019 MAR and TAR for Resident #1 revealed no documentation of the alarms functionality monitoring every shift to ensure proper functioning per the 6/3/19 fall intervention. Medical record review of Resident #1's Nurse's Notes, written by Registered Nurse (RN) #1, dated 7/9/19 at 6:45 PM revealed the RN was notified by (named NA #7) that the RN was urgently needed in Resident #1's room. Further review revealed when the nurse entered the resident's room the Assistant Director of Nursing (ADON) was kneeling beside the resident on the floor applying pressure to the resident's forehead. The resident had fallen from the bed and was against the wall on the right side of the bed. The alarm was sounding intermittently. Review of the Incident/Accident Report, written by RN #1, dated 7/9/19 at 6:45 PM revealed Resident #1 was found on the floor by a visitor to the facility. The visitor then notified NA #7 of the fall and NA #7 then notified the ADON. When RN #1 arrived in Resident #1's room the resident was on the .floor bleeding from forehead on right side of bed (with) back to wall next to window . Further review revealed the ADON held pressure to the wound and the RN applied a pressure dressing. Further review revealed the resident was .1. Sent to ER (emergency room ) for eval (evaluation) and treat (treatment), 2. Bed pad (alarm) applied (New) . Review of the Witness Statement written by NA #2 dated 7/9/19 at 8:00 PM revealed NA #2 was assigned to the resident and the bed pad alarm was sounding intermittently. Review of the facility investigation documentation dated 7/9/19 revealed the pressure pad alarm was not applied correctly and Resident #1 had a .large laceration to R (right) forehead .Newly Implemented interventions: Sent to ER for evaluation + tx (treatment) . Further review of the interdisciplinary team fall investigation revealed in order to reduce reoccurrence the equipment (pressure pad alarm) would be replaced/repaired. Review of the hospital emergency room documentation dated 7/9/19 revealed Resident #1 had a .Laceration: Wound Repair of 8 cm (centimeters) (3.1 in (inch)), subcutaneous (under the skin), laceration to the forehead .Skin closed with 10 .sutures . Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM confirmed she had placed Resident #1 into the bed on 7/9/19 and then left the room to attend to another resident. Further interview revealed .(named ADON) said to get a new one (bed pad alarm) . Telephone interview with RN #1 on 8/13/19 at 9:42 AM revealed .(named NA #7) .said (Resident #1) was on the floor .I saw (named MDS nurse) was in the doorway (of the resident's room) .I said I don't hear the alarm .I asked about the alarm sounding because I didn't hear it. (named NA #2) had put the resident to bed . Observation from 8/6/19 to 9/19/19 at various times during the survey revealed alarms were audible on both units and once activated were continuously audible. Further observation revealed staff responded immediately when the alarm was activated, resident was checked for safety and the alarm was reset by the staff. Interview with the ADON on 8/13/19 at 10:35 AM in the ADON's office revealed a .non-certified technician (NA #7) had come to me and said (RN #1) needed me in (Resident #1's) room. (named MDS nurse) and I .took charge of the scene .(named Resident #1) was sitting on the floor on his buttocks .between the bed and the window. I sent (named RN #1) to get a pressure dressing, and told the non-certified aide to get a washcloth so I could apply pressure .I left him on the floor, made him comfortable, and applied pressure to his forehead .The (bed pad) alarm on the bed was malfunctioning. (named MDS nurse) tested it and sometimes it was working and other times was not working so we replaced the (bed) pad (alarm) . Medical record review of the Physician's Telephone Order dated 7/9/19 revealed .Pressure pad (alarm) on bed @ all times for safety; check for placement + (and) functionality .Tab alarm on bed + chair @ all times for safety; check for placement and functionality .Mats on floor @ all times for safety . Medical record review of the MAR and TAR dated 7/1/19 through 7/31/19 for Resident #1 revealed no documentation of the alarm functionality monitoring every shift to ensure proper functioning. Review of Resident #1's 7/9/19 fall investigation revealed no witness statements from the visitor who alerted NA #7 of the fall, the ADON or the MDS nurse; no documentation of resident's location prior to the fall; how the resident got to the location and no review of the alarm placement and functionality documentation since the 6/3/19 implementation through 7/31/19. Interview with the Administrator, DON, and ADON on 8/13/19 at 1:50 PM in the conference room confirmed the facility failed to monitor the alarm functionality from 6/3/19 through 7/31/19. When they were asked why the 5/1/19 investigation failed to include a statements from CNA #8 and NA #4 and the 7/9/19 investigation failed to include statements from the visitor alerting NA #7 of the fall, the ADON and the MDS nurse, the DON stated .I don't know .we should have . When the DON was asked where Resident #1 was located prior to the 7/9/19 fall and how did the resident get to the location, the DON revealed she .did not ask . When asked if the facility considered the investigation thorough in order to determine the cause of the fall, the Administrator, DON nor the ADON responded. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day MDS dated [DATE] revealed Resident #2 had adequate hearing; had impaired vision and used lenses; and his speech was clear, he could make himself understood and he usually understood others. The resident was cognitively intact with a score of 14 on the BIMS. The resident had evidence of an acute mental status change from baseline and had disorganized thinking present which fluctuated. The resident had exhibited a change in energy level and concentration for 2-6 days of the review period; and exhibited physical behaviors for 1-3 days of the review period. The resident required extensive 1 person assistance for bed mobility, transferring and toileting. The resident required limited 1 person assistance for walking in room and in corridor. The resident was not steady and could only stabilize with staff assistance for moving from seated to standing position, moving on and off the toilet and for surface to surface transferring. The resident was always continent of the bowel and occasionally incontinent of bladder. The resident had fallen 1 month and 2-6 months prior to admission. Review of the Admission Nursing assessment dated [DATE] revealed Resident #2's Fall Risk Evaluation score was 26 indicating he was at high risk for falls. Review of the Admission/Interim Plan of Care (baseline care plan) dated 7/5/19 revealed Resident #2 was identified at risk for falls with a history of falls. The interventions included .PT/OT (Physical Therapy/Occupational Therapy) referral .Instruct resident on safety measures as needed .Requires staff supervision/assistance for safe transfers/ambulation . Review of the Nurse's Notes dated 7/7/19 at 11:00 PM revealed Resident #2 was .alert to person .Confused @ x's (times). Non-compliance (with) safety-RSD (resident) ambulated per self to bathroom this nurse redirected. Assist x 1 (with) ADL's (activities of daily living) + ambulation gait unsteady . Review of the Incident/Accident Report, written by RN #1, dated 7/14/19 at 7:00 AM revealed Resident #2 was heard screaming from the resident's room and was found lying on the floor on the left side complaining of hip and shoulder pain. The resident was assisted to the bed. The resident was sent to the emergency room for a possible fracture. Review of the written statement, by the DON regarding Resident #2's fall revealed on the morning of 7/14/19, around 7:30 AM, RN #1 called the DON to notify the DON Resident #2 had fallen and was sending the resident to the emergency room . RN #1 was in the resident's room doing bed B's accucheck. RN #1 had reported that Resident #2 was in the bathroom without oxygen, unattended, and the RN #1 knew the resident was compromised, due to respiratory status and orthostatic [MEDICAL CONDITION]. Further review revealed RN #1 .went to get a tech (technician), and as I was walking up the ramp it hit me (left resident unattended) and when I went back to (named Resident #2's) room he was in the floor . Review of the handwritten statement, by NA #1 dated 7/16/19 revealed on the morning of 7/14/19 LPN #1 said Resident #2 was on the commode and asked .if I would go check on him . The NA was not aware the resident could get out of bed due to resident's blood pressure dropping so badly when he stood up, let alone walking unassisted. The NA went to the resident's bathroom, asked if the resident needed help, Resident #2 replied with .'Naw, naw' .No, leave me the hell alone.' Then I said 'OK, here's this cord (call light) when you're done pull this so I know you're done and I can help you back to bed, I don't want you to get hurt . Continued review revealed the NA left the resident unattended and about 15 minutes later (named RN #1) was yelling in the hallway the resident was on the floor. The NA entered the resident's room to see the resident sitting on the floor, on the left leg, and the resident was yelling in pain. (named RN #1) was trying to get vital signs but the resident was moving his arms. .RN #1 said, 'Let's move him to the bed.' At that time I felt (named RN #1) being my superior I needed to do as she said . At about 7:00 AM (named LPN #2) came on duty and came to help .(named LPN #2) and (named RN #1) grabbed his legs and I hooked my arms under his arm pits and we got him from the floor to his bed . Interview with the Rehabilitation Director on 8/12/19 at 2:25 PM in the conference room, revealed on the last day of therapy provided on 7/12/19 the resident declined and required moderate to maximum assistance for bed mobility, rolling side to side, scooting and supine to sit and minimum assistance with transferring. Interview with LPN #1 on 8/12/19 at 6:53 AM in the common area, confirmed the LPN was assigned to Resident #2 on 7/13/19 on the 11:00 PM - 7:00 AM shift. Further interview revealed the LPN had checked on the resident and found the resident in the bathroom. Further review revealed .the (resident) must have walked there by .himself .I asked (the resident) if .was ready to get back to bed and (the resident) said 'No' . Continued interview revealed the LPN had left the resident unattended in the bathroom .I sent (named NA #1) to see about the resident in the bathroom .Then a nurse (RN #1) was coming down the hall and he was hollering, and she (RN #1) said the resident fell by the bed .I went to the room and said leave him on the floor .he was complaining of hip pain . Telephone interview with NA #1 on 8/12/19 at 8:08 AM confirmed the NA was assigned to Resident #2 on 7/13/19 on the 11:00 PM - 7:00 AM shift. The NA revealed .Prior to that day I never seen him get out of bed and walk .and (named LPN #1) said (named Resident#2) was in the bathroom. I said who took him to bathroom? (named LPN #1) said I guess he took himself . NA #1 told the nurse the NA would check on the resident in the bathroom. The resident told the NA he was not finished and the NA handed the resident the call light with instruction .to use it, hit it before he needed to get up . Further interview revealed the NA left the resident unattended in the bathroom. The NA heard (named RN #1) hollering after the RN found (named Resident #2) on the floor. Further interview revealed the NA .was not aware the resident couldn't walk. I was not aware the resident was a fall risk .his head was at the head of the bed and his feet were at the foot of bed like he was trying to get in the bed. He went from the bathroom to the bed . Continued interview revealed RN #1 and the NA were in the resident's room when LPN #1 came in and .told us to keep the resident on the floor . and then LPN #1 left. Later .(named RN #1) said we needed to get the resident into the bed. Then the 7:00 AM-3:00 PM nurse came in, me, that nurse and RN #1 picked up resident and put into bed Telephone interview with RN #1 on 8/12/19 at 10:59 AM when asked if the RN had been involved with Resident #2 on 7/13/19 on the 11:00 PM - 7:00 AM shift regarding a fall, the RN revealed .I was working downstairs when LPN #1 .needed help. I went upstairs .was doing the accucheck of Resident #2's roommate (in B bed). I looked around Resident #2 not in the bed .went to dining room. (named LPN #1) said (named Resident #2) was in the bathroom and 'we were checking on him for a while now.' I said 'You can't do that' .I heard him screaming .(named NA #1) came into room and was screaming 'I told (resident) not to get off toilet.' .(named LPN #2), came in the room with us. I ran to (named LPN #1) at the nursing station .when I realized (named LPN #2) came with me and left the resident (alone) with NA #1 . Review of the hospital Emergency Department Record with admitted [DATE] revealed Resident #2 .Arrived per ems\NH (nursing home) staff, pt. (patient) stood to try to use restroom and fell . L (left) leg shortened ext (extremity) rotated. Pt reports pain in hip .Disposition: 7/14/19 Preliminary [DIAGNOSES REDACTED]. Interview with the DON and ADON on 9/12/19 at 2:05 PM in the conference room confirmed the facility had a NA assigned to the resident who was not knowledgeable of his care and did not get supervised when providing care to Resident #2. Further interview confirmed 3 staff members had seen Resident #2 unattended in the bathroom at 3 separate times. Further interview confirmed the facility did not have a thorough investigation and failed to determine the root cause of the fall. Medical record review revealed Resident #8 was readmitted to the facility was on 12/7/17 with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan addressing falls for Resident #8 with an updated intervention dated 3/12/19 revealed .tab alarm on resident at all times on bed/chair . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #8 BIMS score was 5, indicating the resident had severe cognitive impairment and had exhibited disorganized thinking which fluctuated. The resident required limited 1 person assistance for transferring and toileting. Further review revealed a bed and chair alarm was used daily. Medical record review of the 7/2019 Physician's Order revealed Resident #8 had a pull tab alarm at all times while in bed and chair for safety. Review of the facility staffing revealed RN #1, NA #1 and NA #7 were assigned to Resident #8's unit on 8/1/19 for the 3:00 PM 0 11:00 PM shift. Medical record review of the Nurse's Notes dated 8/1/19 revealed Resident #8 was witnessed attempting to self transfer without locking brakes and sat on the floor. The resident was assessed and no injury was noted. Review of the facility investigation documentation, written by RN #2, dated 8/1/19 at 6:00 PM revealed Resident #8 self propelled the wheelchair to the bedside at 5:50 PM and the RN witnessed the resident attempting to self transfer from the unlocked wheelchair to the bedside. The resident then .sat/slide to floor . and no apparent injury was noted. Further review of the investigation revealed a pressure pad alarm (although a tab alarm was ordered) was utilized. Further review of the interdisciplinary team fall investigation revealed a tab alarm and pressure pad alarms (although not ordered) were included in the preventative measures used prior to the fall. Further review revealed the facility investigation failed to clarify the use of the (ordered) tab alarm at the time of the fall, failed to address who placed the alarm(s) on the resident, failed to address if the alarm(s) were activated at the time of the fall, failed to interview the noncertified staff on duty and failed to determine the root cause of the fall. Medical record review of the Physician's telephone Order dated 8/4/19 revealed pull tab alarm at all times while in bed and chair, check every shift for placement. Sensory pad alarm at all times in bed and chair, check every shift for placement and functionality. Medical record review of the (MONTH) and (MONTH) 2019 MAR/TAR revealed the alarm(s) was/were not checked for placement and functionality until 8/4/19. Interview with the DON and ADON on 9/11/19 at 4:30 PM in the conference room confirmed Resident #8 had an order of a tab alarm on at all times when in chair or bed at the time of the fall. Further interview revealed at times the facility did not obtain orders for the alarms. Interview confirmed the facility failed to thoroughly investigate the fall, failed to address if the alarm(s) was/were functioning, failed to interview the noncertified staff and failed to determine the root cause of the fall. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #9 was moderately impaired cognitively with a score of 9 on the BIMS. Continued review of the MDS revealed Resident #9 required limited 1 person assistance with transfers and ambulation; was occasionally incontinent of bladder; and was always continent of bowel. Further review revealed a chair and bed alarm was used daily. Medical record review revealed no physician orders for an alarm(s) for safety. Review of facility investigation revealed on 4/7/19 at 11:40 PM Resident #9 was heard yelling for help. Upon entering the room LPN #1 and CNA #10 found the resident lying on the floor on the left side and partially on the stomach. The resident stated he was getting up to go to the bathroom. No injuries were noted at that time but Resident #9 did complain of back and side hurting. Later the resident complained of a headache and staff noted a hematoma on the left side of his head near the hair line. Continued review of facility investigation included a written statement from CNA #10 dated 4/7/19 revealed .resident (#9) was put to bed before I came in so the alarm was supposed to be already in place but it wasn't turned on therefore no warning before the resident's fall. The nurse evaluated the resident then we picked the resident up off the floor and sat the resident in the wheelchair with the alarm in place in the wheelchair . Further review of the investigation revealed the section on preventative measures in place before the fall failed to mention the alarms. Medical record review of the Nurse's Notes dated 4/8/19 at 1:15 AM, written by LPN #1, revealed Resident #9 stated he .was still hurting some and a hematoma noted to left side of forehead . The note continued at 3:10 AM with .Resident stated back and hip was not hurting now. Stated head and right ankle hurts . The note continued at 7:15 AM with .(named physician) called and stated to send resident to hosp (hospital) . Interview with the DON and ADON on 9/12/19 at 2:55 PM in the conference room revealed Resident #9 got out of bed and fell . Further interview confirmed the facility failed to obtain an order for [REDACTED]. They confirmed the alarm was not turned on at the time the resident fell . They also confirmed there was an incomplete investigation with no documentation of the presence of bed and chair alarms, no interview from CNA #8 assigned to Resident #9 on 4/7/19 on the 3:00 PM - 11:00 PM regarding the alarm not turned on and no root cause determination. Medical record review revealed Resident #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #13 was severely cognitively impaired with a score of 3 on the BIMS. Further review revealed the resident required limited 1 person assistance for transferring and ambulation in the room and required extensive 1 person assistance for toileting. The resident had no prior falls. Further review revealed the chair alarm was used less than daily and the bed alarm was used daily. Medical record review of the 6/2019 and 7/2019 Physician's Orders revealed Resident #13 had a .sensory (pressure) pad alarm while in chair and bed .tab alarm at all times in bed and chair for safety . Medical record review of the Nurse's Notes dated 7/12/19 revealed LPN #2 saw Resident #13 in a wheelchair, outside the resident's room, as the LPN was going to assist another resident. When the LPN finished with the other resident and went past Resident #13's room the LPN saw Resident #13 lying on the left side on the floor in the resident's room. The resident stated she was trying to go to the bathroom when her knees gave out and she denied any pain or discomfort. Review of the Incident/Accident report dated 7/12/19 at 10:45 AM revealed Resident #13 was found on the floor in front of the wheelchair in the resident's room. Review of the facility investigation documentation dated 7/12/19 for Resident #13 revealed no witness statements had been completed. Further review revealed the bed/chair alarm had not been correctly applied. Further review revealed the investigation did not specify if the alarm(s) which were to be used were a pressure pad and/or tab alarm. Further review revealed CNA (#9) was to be educated on the importance of the placement of the alarms. Review of the interdisciplinary team investigation revealed the preventative measures in place before the fall included both a tab and pressure alarm on the bed and chair and the corrective measure to reduce reoccurrence was to replace the pressure pad alarm. Medical record review of the 6/2019 and 7/2019 MAR and TAR revealed the facility failed to address the placement and functionality of the tab and pressure pad alarms. Interview with CNA #9 on 9/1/19 at 8:55 AM on 200 hall confirmed the CNA was assigned to Resident #13 on 7/12/19. The CNA revealed she was working alone that day and doing bed baths and the nurse (LPN #2) was helping dress the resident (#13). Further interview revealed Resident #13 .was bad about taking the tab alarm off back then . The CNA had no recall if the alarms were in place on 7/12/19. The CNA confirmed the CNA did not complete a witness statement regardin

Based on facility policy review, medical record review, review of the facility investigation, interview and employee record review, the facility failed to ensure 1 resident (#5) of 13 residents reviewed was free from abuse when a noncertified Nurse Aide (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) repeatedly splashed water in the resident's face during a shower resulted in psychosocial Harm. The findings include: Review of the undated facility policy, Abuse, Neglect, Misappropriation of Property & (and) Exploitation, revealed .Definitions: Abuse - the willful infliction of injury .intimidation, pain or mental anguish .Each Resident .has the right to be free from mistreatment .Identification: identify events, such as suspicious bruising .occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation .It is the responsibility of the staff .to prohibit and prevent any Resident from Abuse . Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum (MDS) data set [DATE] revealed Resident #5 was severely cognitively impaired with a score of 6 on the Brief Interview for Mental Status. Further review revealed the resident's hearing and vision were adequate, required lenses for vision; had clear speech, made self-understood, and understood others. The resident required extensive 1 person assistance for bathing and limited 1 person assistance for transferring. Review of the Incident/Accident Report dated 6/13/19 revealed the Director of Nursing (DON) was notified of the incident on 6/14/19 at 11:00 AM. Further review revealed Certified Nurse Aide (CNA) #6 reported to Licensed Practical Nurse (LPN) #4 that Resident #5 was in the shower and NA #3 was .splashing water in resident's face during shower .purposely, when she tried to speak . Review of the written statements addressing the incident on 6/13/19 involving Resident #5 revealed the following: NA #2's undated written statement revealed .On (MONTH) 13th, 2019 between hours of (10:00) AM-12:00 PM I witnessed a patient being treated in a wrongful manner. I saw (named NA #3) splashing (named Resident #5) in the face every time she would say something .and (named NA #3) would just laugh about it when doing it. (Named Resident #5) would yell for (named NA #3) to stop it and she would splash (resident) again . LPN #3's written statement dated 6/13/19 at 11:00 AM revealed .(named NA #2) came to me said you might (want to) say something to (named NA #3). (Named NA #3) was rude + (and) ugly to (named Resident #5) in the shower. I immediately went to the resident and ask if anybody was rude, ugly or mean to her and she said 'no, they're not' . LPN #4's written statement dated 6/14/19 revealed .This morning a technician (CNA #6) told me that (named NA #3) .gave a resident a shower yesterday and kept spraying the resident in the face with water. She said when the resident would try to talk she (NA #3) would spray her in the face. I let my DON know as soon as I was told . Telephone interview with NA #3 on 8/13/19 at 5:07 PM revealed .(named NA #2) took resident (#5) to the .shower room, with (named CNA #6) and me. We went in and .I told (named NA #2) no way to really clean (named resident) good and she needed a shower anyway .We got her set up for the shower and (named CNA #6) left and never came back .Then (named NA #2) left me alone in the room with the resident and I was trying to get the water warmed up and wet her hair. I soaped .her hair, washed .her .and was still alone .Soap got in her eyes and she said she would report me. I said for what, for getting soap out of her eyes? And she said 'Yes' . Further interview revealed (named NA #2) and (named CNA #6) were not in the room during the shower. Telephone interview with NA #2 on 8/12/19 at 5:28 PM revealed Resident #5 .was in the shower with (named NA #3) and (named CNA #6) and me. (named Resident #5) was talking with (named NA #3) and she splashed water in the resident's face. I told (named NA #3) it was not okay, and I said it again not to do that. Then I left the shower and told (named LPN #3) and nothing got done so I went to the DON and ADON (Assistant Director of Nursing) . Telephone interview with CNA #6 on 8/14/19 at 9:51 AM revealed .6/13/19 was my first day of work there and I was in training with (named CNA #2) .I went into the shower room and (named NA #2) and (named NA #3) were with the resident (#5) and (named NA #3) sprayed water in the resident's face and laughed about it. (Named Resident #5) was saying something and I didn't understand what. It was my first day and I didn't know what to do or who to tell so I left the room . Further interview revealed (named NA #3) and (named NA #2) .were both laughing and I didn't think it was funny. (named NA #2) didn't say anything to (named NA #3) to stop it .she was laughing and I left. (named NA #2) and (named NA #3) were in the shower room when I left . When asked why CNA #6 didn't tell anyone, CNA #6 revealed .I know I told a nurse but I think it was the day after and then she got up and told the DON . Interview with Resident #5 on 8/14/19 at 10:57 AM in the first floor dining room revealed the resident recalled the incident during a shower involving getting her face sprayed with water. Further interview with the resident revealed .I was getting a shower and a tech (technician (NA #3)) was spraying water in my face and I didn't want her to do it . When asked if the resident thought the technician was trying to get soap off of her face or eyes, the resident stated .No, she was just doing it . When asked if there were other staff in the shower room the resident revealed .Yes, a couple, and they were laughing about it . When asked if anyone tried to stop the technician from spraying water in her face, the resident revealed .No .I had to play along and they just laughed. I don't want that to happen again . When asked if the resident remembered the technician's name who was doing the spraying or who was in the shower room at the time, the resident revealed .No, not anymore, but haven't seen her, the one that sprayed me . Interview with the DON on 8/13/19 at 4:18 PM in the conference room confirmed the CNAs and the NAs did not have competency verification. Further interview revealed the facility did not substantiate the incident as abuse because the resident .said she was okay . Employee record review revealed the facility failed to ensure Nurse Aides had abuse registry verification prior to providing direct resident care for 4 employees (#1, #2, #8, #9) of 11 employee records reviewed. Interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Business Office Manager on 8/14/19 at 5:05 PM and on 8/15/19 at 4:00 PM in the conference room, when asked if the employees were required to have abuse registry verification prior to having direct resident care, the Administrator confirmed all staff were to have abuse registry verification before any resident contact. The facility is required to submit a Plan of Correction.

Based on medical record review, facility incident investigation and interview, the facility failed to notify the physician and the resident representative of an incident and subsequent pain and [MEDICAL CONDITION] after a fall for 1 resident (#10) of 13 residents reviewed. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #10 was cognitively intact with a score of 14 on the Brief Interview for Mental Status. Further review revealed the resident required limited 1 person assistance for transferring and extensive 1 person assistance for toileting. Further review revealed the resident had a fall with no injury during the review period. Review of the facility investigation documentation, written by Licensed Practical Nurse (LPN) #7, revealed the incident occurred on 5/21/19 at 3:40 PM in Resident #10's bathroom. Further review revealed the resident pushed the alert button in the bathroom and was .found hanging off the w/c (wheelchair)/commode, almost falling Further review revealed LPN #7 told the resident she was going to sit the resident on the floor and get help. Further review revealed the LPN and noncertified Nurse Aide (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) #2 put the resident into the wheelchair, provided incontinence care and no injury was identified. Further review revealed the resident .mentioned no pain . Further review revealed the physician and the resident representative had not been notified of the fall. Medical record review of the Nurse's Notes, written by LPN #5, dated 5/21/19 at 10:00 PM, over 6 hours after the fall, revealed Resident #10 was .complaining of RLE (right lower extremity) pain, right knee and right ankle [MEDICAL CONDITION] (swollen) . Further review revealed the resident stated she had fallen .yesterday . Continued review revealed the nurse .noted [MEDICAL CONDITION] to (right) ankle and elevated . Further review revealed no notification to the physician or the resident representative of the development of the pain or [MEDICAL CONDITION] after the fall. Telephone interview with LPN #5, on 9/19/19 at 9:30 AM, confirmed the LPN failed to notify the physician or the resident representative of the resident's complaint of pain and the [MEDICAL CONDITION] after a fall. Interview with the Director of Nursing and the Assistant Director of Nursing on 9/12/19 at 2:05 PM in the conference room revealed the physician and resident representative were to be notified of all falls. Further interview confirmed the physician and resident representative were not notified of the fall on 5/21/19 at 3:40 PM and were not notified at 10:00 PM when the resident complained of pain and had [MEDICAL CONDITION] of the right ankle.