Every finding on record at Heritage Place Care & Rehabilitation LLC

Based on facility policy review, job description review, current employee list review, and interviews, the facility failed to designate an individual as the Infection Preventionist with completion of specialized training in Infection Prevention and Control, which had the potential to affect 75 of 75 residents. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 2024, revealed .The designated Infection Preventionist is responsible for oversight of the program .infectious diseases .implementing isolation .serves as the leader in surveillance activities .maintains documentation .reports surveillance findings . Review of the facility's undated job description titled, Infection Control, revealed .Infection Control is responsible [for] the Infection Prevention Program .Education/Experience: Completion of training on infection prevention . Review of the facility's current employee listing dated 4/7/2026, revealed no employees with a role of Infection Control or Infection Preventionist. During an interview on 4/7/2026 at 10:30 AM, the Director of Nursing (DON) stated the previous Infection Preventionist (IP) left the facility's employment at the end of 12/2025 or beginning of 1/2026 (3 months prior). The DON stated, .there isn't an IP nurse right now . Licensed Practical Nurse (LPN) A has been doing the Infection Control stuff since 1/2026 . During an interview on 4/7/2026 at 10:40 AM, LPN A stated, .the Infection Control books were in the office I use .the previous Regional Nurse emailed me 1/2026's Infection Control Log in February for QAPI [Quality Assurance and Performance Improvement] meeting and emailed me 2/2026's Infection Control Log in March for QAPI .I've tried to keep up with residents requiring Transmission or Enhanced Barrier Precautions .[LPN B] is supposed to do Infection Control now . LPN A confirmed she [LPN A] had not received Infection Control training and was not an Infection Preventionist. During an interview on 4/7/2026 at 10:50 AM, LPN B stated, .I was told yesterday [4/6/2026] that I would start doing Infection Control . LPN B stated she [LPN B] had not received any training in Infection Control and was told by the new Regional Nurse she needed to complete the Centers for Disease Control (CDC) training program and was unsure of the date the training was to begin. During an interview on 4/8/2026 at 2:00 PM, LPN B confirmed she had not enrolled or started an Infection Control training program at this time. During an interview on 4/8/2026 at 2:04 PM, the DON confirmed there were no nurses at the facility with the required Infection Preventionist training, and the facility had not had an Infection Preventionist for the last 3 months.

Based on facility policy review, facility Infection Surveillance documents review, and interviews, the facility failed to ensure implementation of an effective Antibiotic Stewardship Program to identify specific or potential infectious outbreaks, identify, report, and track antibiotic usage which had the potential to affect 75 of 75 residents. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 2024, revealed .A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases . Review of the facility's policy titled, Antibiotic Stewardship Program, dated 2023, revealed .The purpose of the [Antibiotic Stewardship] program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistant patterns in the facility . Review of the undated Infection Control monthly surveillance log for 1/2026, revealed several residents received antibiotics for multiple types of symptoms and/or infections, which included 6 residents with Influenza. The log contained no room numbers, and the facility map was blank with no data indicating tracking or trending of the infections. Review of the undated Infection Control monthly surveillance log for 2/2026, revealed several residents received antibiotics for multiple types of symptoms and/or infections. The log contained no room numbers, and the facility map was blank with no data indicating tracking or trending of the infections. During an interview on 4/7/2026 at 10:30 AM, the Director of Nursing (DON) stated the previous Infection Preventionist (IP) left the facility's employment at the end of 12/2025 or beginning of 1/2026 (3 months prior). The DON stated, .there isn't an IP nurse right now . Licensed Practical Nurse (LPN) A has been doing the Infection Control stuff since 1/2026 . During an interview on 4/7/2026 at 10:40 AM, LPN A stated, .we haven't been tracking antibiotics when they are ordered as far as I know .the antibiotic report is printed from the Electronic Health Record at the beginning of the month for the entire previous month, and then the log is filled out .the previous Regional Nurse emailed me 1/2026's Infection Control log in February for QAPI [Quality Assurance and Performance Improvement] meeting and emailed me 2/2026's Infection Control log in March for QAPI meeting . LPN A stated there was no Infection Control monthly surveillance log for 3/2026. During an observation and interview on 4/8/2026 at 2:04 PM, the DON confirmed she (the DON) was not aware of the diseases that were reportable to the State of Tennessee Health Department and confirmed the Influenza outbreak in 1/2026 was not reported to the State. The DON confirmed antibiotics have not been monitored proactively, infection tracking and trending has not been completed, and confirmed there was no Infection Control monthly surveillance log for 3/2026.

Based on facility policy review, manufacturer guideline review, observations, and interviews, the facility failed to monitor refrigerator temperatures daily, maintain correct temperatures, and properly store medications and/or biologicals in 2 of 3 medication rooms reviewed.The findings include: Review of the facility's policy titled, Storage of Medication Requiring Refrigeration, dated 4/2026, revealed .The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates .ensure that all medications and biologicals will be stored at proper temperatures .Refrigerated refers to temperature maintained between 36 - 46 degrees Fahrenheit .refrigerators used for the storage of medications and biologicals .temperature to be monitored daily to ensure proper temperature control and documented on the temperature log . Review of the undated manufacturer guideline titled, TUBERSOL - tuberculin purified protein derivative [TB ppd] injection [an injectable medication used to detect the bacteria that causes Mycobacterium tuberculosis], revealed .Storage .This product should be stored between .35* [degrees] F (Fahrenheit] to 46*F .a vial of TUBERSOL which has been entered and in use for 30 days should be discarded .due to possible oxidation and degradation which may affect potency . Review of the undated manufacturer guideline titled, FLUAD - Seqirus Inc [influenza vaccine], revealed, .Store FLUAD refrigerated at .36*F to 46*F .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . During an observation and interview on 4/8/2026 at 1:47 PM, the Alzheimer's Care Unit (ACU) medication room refrigerator revealed a 30 milliliter (ml) opened multi-dose vial of TB ppd, the vial was 3/4 full and was labeled with an open date of 10/4/2025. Licensed Practical Nurse (LPN) C confirmed the opened vial of TB ppd was labeled with an open date of 10/4/2025 and was available for resident use. LPN C stated the vial was approximately 6 months past the open date and should have been discarded after 30 days. Further observation revealed the refrigerator temperature log had spaces for daily monitoring of the temperature, with instructions .temperature should not be greater than 40 degrees Fahrenheit, or less than 37 degrees Fahrenheit . The temperature log was blank 3 of 7 days (4/1/2026, 4/2/2026, and 4/5/2026), and the temperatures recorded on 4 of 7 days was 32 degrees Fahrenheit (4/3/2026, 4/4/2026, 4/6/2026, and 4/7/2026) which was out of the range per the directions, facility policy, and manufacturer guideline, with no documented corrective action. During an observation and interview on 4/8/2026 at 4:00 PM, the B-Wing medication room refrigerator revealed a 30 ml opened multi-dose vial of TB ppd, the vial was 1/2 full and was not labeled with an open date. The pharmacy label revealed the TB ppd vial was sent to the facility on 9/5/2025. The Director of Nursing (DON) confirmed the opened vial of TB ppd was not labeled with an open date, was sent to the facility on 9/5/2025, and was available for resident use. The DON stated the vial was approximately 7 months past the open date and should have been discarded after 30 days. Further observation revealed the refrigerator temperature log had spaces for twice daily monitoring of the temperature. The temperature log was blank on 4 day shifts and 4 night shifts (4/2/2026, 4/3/2026, 4/4/2026, and 4/5/2026). During an interview on 4/8/2026 at 4:05 PM, the DON confirmed TB ppd vials should be dated when opened and should be discarded within 30 days of opening, were not discarded and available for resident use. The DON confirmed both medication room refrigerator temperatures were not documented daily, and the ACU refrigerator temperatures containing TB ppd and Influenza vaccines were out of range.

Based on facility policy review, activity calendar review, observations, and interviews, the facility failed to ensure an ongoing program of activities were implemented in the Alzheimer's Care Unit (ACU) to meet the needs and interests of the residents, which had the potential to affect 20 of 20 residents residing in the ACU.The findings include: Review of the facility's undated policy titled, Activities Program, revealed .Facility will develop specialized activities for residents with Alzheimer's Disease and/or other Dementia related conditions. Nursing and Social Services Director (SSD) will assist with this endeavor .The Activity Director will see that supplies are available for activities . Review of the ACU's Activity Calendar Memory Springs dated 4/2026, revealed the following activities:4/6/2026 Morning: Monday Manicures, 1:1 Visits; Afternoon: Movie, Milk and Cookies. 4/7/2026 Morning: Arts and Crafts, Balloon Volley; Afternoon: Patio Time, Music and Soda4/8/2026 Morning: Sit and Be Fit Table, Sensory; Afternoon: Table Top Games, Snack Social During observations of the ACU 4/6/2026, 4/7/2026, and 4/8/2026, revealed a lack of ongoing activity programming to meet the needs of the resident population as noted by the following:During frequent intermittent observations on 4/6/2026 from 8:00 AM to 12:30 PM, revealed there were no activities taking place on the unit and no items for sensory stimulation out and offered to the residents. 5 residents were in the dining room seated at empty tables with the television (TV) on a news channel, the volume was low and inaudible. 2 residents were wandering in the hallway, and in and out of other resident rooms. Residents were often redirected by staff to the dining room. The television (TV) was on in the dining room with the volume low and inaudible. During frequent intermittent observations on 4/6/2026 from 1:45 PM to 4:00 PM, revealed 3 residents in the dining room seated at empty tables, and the TV was turned off. 2 residents were wandering in the hallways with 1 sitting by the exit door, 1 resident was wandering in the hallway, and in and out of other resident rooms. There were no activities taking place, nor were any sensory stimulation or independent leisure supplies out or offered. During frequent intermittent observations on 4/7/2026 from 8:00 AM to 1:00 PM, revealed 5 residents were in the dining room sitting at empty tables, and the TV was turned off. 2 residents were wandering in the hallways with 1 resident wandering in and out of other resident rooms. The residents were redirected by staff to the dining room. There were no activities taking place, nor were any sensory stimulation or independent leisure supplies out or offered. During frequent intermittent observations on 4/7/2026 from 2:15 PM to 3:30 PM, revealed no activities were taking place in unit. Several residents were ambulating in and out of the dining room, wandering the halls, and in and out of other resident rooms. The TV was on in the dining room with the volume low and inaudible. Residents in the dining room were seated at empty tables with no items for activity or stimulation available. During the frequent observations from 4/6/2026 - 4/8/2026 on the ACU, revealed the scheduled activities noted on the ACU calendar did not occur. During an interview on 4/8/2026 at 3:00 PM, Licensed Practical Nurse (LPN) C confirmed she worked 7:00 AM to 7:00 PM on 4/6/2026, 4/7/2026, and 4/8/2026. LPN C stated, .they [activities] haven't been on this unit for activities from 4/6/2026 until late yesterday [4/7/2026] around 3:30-4:00 PM, they came and did some painting .one of them [activities personnel] has been out of work and just returned .hopefully it will get better .we [ACU nurses and CNA's] do the best we can . During an interview on 4/8/2026 at 3:15 PM, CNA E confirmed she worked 7:00 AM to 7:00 PM on 4/6/2026, 4/7/2026, and 4/8/2026. CNA E stated, .the activity person is busy on the other side [of the facility] .there is only one person right now, but the other one just returned to work .we [ACU nurses and CNA's] try to do things with them when we can, we take them to the patio, put the TV on, but it's not enough for these residents, and we have our jobs to do too . During an interview on 4/8/2026 at 4:30 PM, the Activities Director (AD) confirmed the residents on the ACU had limited activities.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure expired foods were not available for resident use for 3 residents (Residents #9, #65, and #8) of 11 resident personal refrigerators observed. The findings include: Review of the facility's policy titled, Resident Refrigerators, dated 4/1/2026, revealed .it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators .staff shall .discard any foods that are out of compliance .Foods with use-by dates shall be discarded accordingly . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Morbid Obesity, and Functional Quadriplegia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation in Resident #9's room and interview on 4/6/2026 at 11:19 AM, Resident #9's personal refrigerator revealed 1 unopened half pint milk carton with a manufacturer's use by date of 3/31/2026 (6 days past use by date) and 1 opened 1 gallon jug (approximately 2/3's full) of milk with a manufacturer's use by date of 4/2/2026 (4 days past the use by date). Licensed Practical Nurse (LPN) D confirmed the 1 unopened half pint of milk and the 1 gallon jug of milk was expired and available for resident use. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Essential Hypertension, and Hyperlipidemia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #65 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. During an observation in Resident #65's room and interview on 4/6/2026 at 12:11 PM, Resident #65's personal refrigerator revealed 1 unopened carton of milk with a manufacturer's use by date of 2/16/2026 (49 days past the use by date). LPN D confirmed the milk was expired and available for resident use. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Vascular Dementia, and Primary Osteoarthritis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. During an observation in Resident #88's room and interview on 4/6/2026 at 12:13 PM, Resident #8's personal refrigerator revealed 3 unopened milk cartons with a manufacturer's use by date of 3/16/2026 (21 days past the use by date) and 1 unopened No Bake Blueberry Cheesecake Parfait with a best if used by date of 3/2/2026 (35 days past the use by date). LPN D confirmed the food items were expired and available for resident use. During an interview on 4/8/2026 at 12:36 PM, the Director of Nursing stated it was the responsibility of the nursing department to check resident personal refrigerators at the beginning of each week and confirmed it was her expectation for outdated items to be discarded and not available for resident use. The DON further confirmed the expired food items had not been discarded and were available for resident use.

Based on record review and interview, the facility failed to manage the Resident Trust Accounts for 8 (Resident #2, Resident #6, Resident #8, Resident #11, Resident #43, Resident #49, Resident #54 and Resident #60) of 43 residents' trust accounts reviewed to ensure they did not exceed the allowable Medicaid limit of $2,000. The findings include: Review of the facility's Trial Balance statement showed the following residents' trust accounts contained more than the Medicaid allowable amount of $2,000 which could result in the resident being ineligible for Medicaid benefits: Resident #2 $2,419.13 ($419.13 over the limit) Resident #6 $8,240.66 ($6,240.66 over the limit) Resident #8 $2,740.27 ($740.27 over the limit) Resident #11 $3,647.66 ($1,647.66 over the limit) Resident #43 $2,849.44 ($849.44 over the limit) Resident #49 $4,956.62 ($2,956.62 over the limit) Resident #54 $3,275.56 ($1,275.56 over the limit) Resident #60 $2,063.04 ($63.04 over the limit) During an interview on 7/12/2023 at 8:10 AM, the Regional Business Office Consultant stated regulations showed every resident Medicaid trust account should have no more than $2,000 in it and confirmed Resident #2, Resident #6, Resident #8, Resident #11, Resident #43, Resident #49, Resident #54 and Resident #60's trust accounts had more than the $2,000 allowable limit for Medicaid eligibility.

Based on review of facility policy, medical record review, facility investigation, observation and interview, the facility failed to prevent abuse of 1 resident (Resident #1) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention Program updated 1/19/2017 showed .It is the policy of this facility to prevent resident abuse .Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment .Physical Abuse: Hitting, slapping, pinching, kicking etc . Resident #1 was admitted to the facility on [DATE] with diagnoses including Disorder of Brain, Bipolar Disorder, Dementia and Cirrhosis of Liver. Medical record review of Resident #1's Progress Notes dated 10/1/2022-10/23/2022 showed no behaviors toward others, the resident was being evaluated by group homes for possible transfer. Medical record review of Resident #1's History and Physical dated 10/6/2022 showed .Past medical history: Nontraumatic subarachnoid hemorrhage .Senile degeneration of the brain .Bipolar disorder . Medical record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Delusions were observed during the observation period, with no other behaviors observed. The resident required extensive assistance of 2 physical assist for bed mobility, transfer, toilet use and extensive assist of 1 physical assist for dressing and personal hygiene. Resident #1 required limited assistance of 1 person physical assist for locomotion on and off the unit. Medical record review of Resident #1's Nursing Progress Note dated 10/24/2022 showed .resident was observed receiving physical contact from another resident in hall at front lobby entrance. Resident was immediately removed from situation and assessed, no apparent injuries noted .new order noted to place resident 1:1 [one on one] for closer observation until sent out to hospital. Other new order noted to send resident to ER [emergency room ] for medical clearance .neuro [neurological] checks initiated and WNLs [within normal limits] resident denies pain .Report called to ER and ambulance in route . Review of a facility investigation dated 10/24/2022 at 3:23 PM showed .[Resident #2] was seen by the Unit Manager [UM] making physical contact with other resident [Resident #1] and called out for assistance .Unit manager was standing by HR [Human Resource] door on the other side of entry doors in front lobby. Unit Manager statement: 'I turned around from HR door and saw [Resident #2] hitting [Resident #1] [Resident #2] had a closed fist. [Resident #1] was holding his arms up trying to block [Resident #2] .[Resident #2] hit [Resident #1] in the head multiple times .Residents were immediately separated. DON [Director of Nursing] assisted with removing [Resident #2] as I moved [Resident #1] .[Resident #2] said he hit [Resident #1] with walker. [Resident #1] stated [Resident #2] hit him with walker. I did not see [Resident #2] hit [Resident #1] with walker .3:23 PM .both residents placed on 1:1 .3:25 PM .both residents were assessed by DON, UM, ADON [Assistant Director of Nursing] no apparent injuries. Both residents denied pain. [Resident #1] stated 'he hit me in my head' and rubbed on his head but denied pain with no pain indicators. neuro checks initiated on both residents .3:37 PM .administrator notified .3:30 PM .police notified/arrive .new orders noted to send both residents to ER for evaluation .3:35 PM .Police arrived and obtained report. Stated they were not going to arrest [Resident #2] because he had dementia and was 84 yo [years old] .3:55 PM .EMS [Emergency Management Services] X2 arrive and transferred both residents to [hospital] . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Dysphagia, Muscle Wasting and Atrophy, Congestive Heart Failure, Schizophrenia, Psychotic Disorder with Delusions, Hallucinations and Bipolar Disorder. Medical record review of Resident #2's annual MDS dated [DATE] showed a BIMS score of 6 indicating severe cognitive impairment. The resident had verbal behavioral symptoms directed toward others 4 to 6 days, other behavioral symptoms not directed toward others daily, and wandering behaviors daily during the assessment period. The resident required extensive assistance of 2 staff for bed mobility, transfer and toilet use. Extensive assist of 1 for dressing and personal hygiene and limited assistance of 1 for walking. Medical record review of Resident #2's General Progress Note dated 10/17/2022 showed .re admit from [psychiatric hospital] . Medical record review of Resident #2's Nursing Progress Note dated 10/18/2022 showed .follow up from Readmit, Resident has been calm and cooperative, denies pain. Resident self ambulates and walks hallway wanting snacks frequently . Medical record review of Resident #2's Psychiatric Evaluation dated 10/18/2022 showed .Resident readmitted to the facility on [DATE] from inpatient psychiatric hospital. Resident was admitted to psych hospital d/t [due to] increased physical and verbal aggression. Staff reports since he readmitted yesterday, he has not had any aggression or agitation . Medical record review of Resident #2's Social Service Note dated 10/19/2022 at 9:17 AM showed .Resident took house shoes from another resident and wore them all day refusing to take them off when asked. When SSD [Social Service Director] asked him to take them off resident urinated in them. Staff eventually got the house shoes and took them to laundry . Medical record review of Resident #2's General Progress Note dated 10/20/2022 at 3:52 AM showed .resident was in bed sleeping at beginning of shift but when woke up to give meds has been restless and wandering since approx. [approximately] 9:30 PM this shift, has continued to ask staff random questions. Will continue to observe .receives PRN [as needed] medications to help with anxiety and pain . Medical record review of Resident #2's Nursing Progress Note dated 10/24/2022 at 3:23 PM showed .resident observed making physical contact with another resident in front hall near lobby. Staff intervened and separated immediately. Resident assessed with no apparent injuries .New orders noted to place resident 1:1 immediately and to send resident out to hospital for further evaluation . Medical record review of Resident #2's General Progress Note dated 10/24/2022 at 3:55 PM .resident left facility via [by] ambulance . Medical record review of Resident #2's General Progress Note dated 10/24/2022 at 7:00 PM .resident arrived back to facility in stable condition .continue 1:1 observation . Medical record review of Resident #2's General Progress Note dated 10/24/2022 at 9:45 PM .currently resting in bed with 1:1 observation in place. No behaviors noted at this time . Medical record review of Resident #2's Psychiatric Evaluation dated 10/25/2022 showed .Resident had physical altercation with another resident yesterday. He was sent to the ER and then returned after .he was recently discharged from inpatient psych [psychiatric hospital]. Resident does recall this event and stated he was trying to get money from the business office and the other resident would not get out of his way. He has been 1:1 with staff since event. He continues to be restless and requires frequent redirection . During an interview with Resident #1 on 11/7/2022 at 9:05 AM, when asked about the incident he stated .I don't know he just don't like me. He hit me on my back, head, and neck. He hit me with his walker . He stated there had not been an exchange of words except he had been sitting at the lobby glass doors and Resident #2 had said [NAME] move go on and Resident #2 got mad when he had to wait for Resident #1 to move. Resident #1 stated he was not afraid then or now, he was just staying away from Resident #2. During an interview with Licensed Practical Nurse (LPN) #1/UM on 11/8/2022 at 8:05 AM, she stated .I was in the Human Resource [HR] Office on the front lobby side of the glass doors, I turned around to speak to the DON. Out of my side view I saw arms in the air, so I looked, and I realized they were fighting. I ran out of the HR office to the hall. The DON was right behind me. We immediately separated the residents and kept them separated. I stayed in the hallway with [Resident #2]. I saw [Resident #2] hitting [Resident #1] in the head with his hands. [Resident #1] had his hands up trying to protect himself. I asked [Resident #2] what happened. He said he walked up and asked [Resident #1] to move and [Resident #1] said 'no go around'. He was setting with his wheelchair against the glass door on the left. [Resident #2] said he pushed [Resident #1] and he still didn't move so I hit him. I asked him why did he do that and he said because he was in the way, and he wouldn't move .It was [Resident #2's] intention to hit [Resident #1]. His actions were willful. He wanted him out of his way . During an interview with the Social Service Director (SSD) on 11/8/2022 at 12:15 PM, she stated .I went out of my office when the incident occurred. [Resident #1] was upset and a little shaken up from the incident. We brought him in the conference room for a while, he calmed down quickly and was able to return to his room. I checked on him when he returned from the hospital. I see him almost daily and there has been no change in his emotional behavior. He isn't withdrawn, fearful, he is still very outgoing, friendly, and social .The resident remained separated until discharged from the facility .I saw [Resident #2] almost daily, his outbursts prior to this had not been addressed at others, it was mainly about his money. He was so insistent about getting all of his money out his account. He would come to the front office and beat on the door. He wasn't exit seeking he would just want money .I checked on him [Resident #2] every day I was here. He did recall the incident and would say 'I just pushed him out of the way because he wouldn't move' . During an interview with the DON on 11/9/2022 at 2:50 PM, she stated .I was in the conference room which is off the lobby. I heard the unit manager call for help she stated these residents are fighting. I ran around the corner [UM] was entering the door code before I went through the doors. I saw [Resident #2] make physical contact with [Resident #1] with his closed fist to [Resident #1]'s head . During the interview the DON confirmed Resident #2 was witnessed willfully hitting Resident #1 in the head with his fist. Observation of Resident #1 on 11/8/2022 at 3:05 PM, in the hallway just outside his room, showed the resident self-propelling into his room, he was awake, alert, pleasant, and no anxiety or fearful behaviors were observed. During an interview with the Administrator on 11/10/2022 at 9:30 AM, he stated .it was a witnessed event staff did see [Resident #2] hit [Resident #1] with his open hands. [Resident #2] did admit to hitting [Resident #1] . During the interview the Administrator confirmed the facility failed to prevent abuse of Resident #1.

Based on review of facility policy, medical record review, facility investigation and interview, the facility failed to report investigation outcome findings on 1 facility self-reported incident of 2 facility self-reported incidents reviewed. The findings included: Review of a facility policy Abuse Prevention Program updated 1/19/2017 showed .Procedure .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately .Abuse involving one resident upon another resident will be reported to TDH [Tennessee Department of Health]. The investigator will submit a final report of the conclusion of the investigation in writing within five (5) working days of the incident . Resident #1 was admitted to the facility on [DATE] with diagnoses including Disorder of Brain, Bipolar Disorder, Dementia and Cirrhosis of Liver. Medical record review of Resident #1's Progress Notes dated 10/1/2022-10/23/2022 showed no behaviors toward others, resident was being evaluated by group homes for possible transfer. Medical record review of Resident #1's History and Physical dated 10/6/2022 showed .Past medical history: Nontraumatic subarachnoid hemorrhage .Senile degeneration of the brain .Bipolar disorder . Medical record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Delusions were observed during the observation period, with no other behaviors observed. Medical record review of Resident #1's Nursing Progress Note dated 10/24/2022 showed .resident was observed receiving physical contact from another resident [Resident #2] in hall at front lobby entrance. Resident was immediately removed from situation and assessed, no apparent injuries noted .new order noted to place resident 1:1 for closer observation until sent out to hospital. Other new order noted to send resident to ER [emergency room ] for medical clearance .neuro [neurological] checks initiated and WNLs [within normal limits] resident denies pain .Report called to ER and ambulance in route . Review of a facility investigation dated 10/24/2022 at 3:23 PM showed .Resident #2 was seen by the Unit Manager [UM] making physical contact with other resident [Resident #1] and called out for assistance .Unit manager was standing by HR [Human Resource] door on the other side of entry doors in front lobby. Unit Manager statement: 'I turned around from HR door and saw [Resident #2] hitting [Resident #1] [Resident #2] had a closed fist. [Resident #1] was holding his arms up trying to block [Resident #2] .[Resident #2] hit [Resident #1] in the head multiple times .Residents were immediately separated. DON assisted with removing [Resident #2] as I moved [Resident #1] .[Resident #2] said he hit [Resident #1] with walker. [Resident #1] stated [Resident #2] hit him with walker. I did not see [Resident #2] hit [Resident #1] with walker .3:23 PM .both residents placed on 1:1 .3:25 PM .both residents were assessed by DON, UM, ADON [Assistant Director of Nursing] no apparent injuries. Both residents denied pain. [Resident #1] stated 'he hit me in my head' and rubbed on his head but denied pain with no pain indicators. neuro checks initiated on both residents .3:37 PM .administrator notified .3:30 PM .police notified/arrive .new orders noted to send both residents to ER for evaluation .3:35 PM .Police arrived and obtained report. Stated they were not going to arrest [Resident #2] because he had dementia and was 84 yo [years old] .3:55 PM .EMS [Emergency Management Services] X2 arrive and transferred both residents to [hospital] . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Dysphagia, Muscle Wasting and Atrophy, Congestive Heart Failure, Schizophrenia, Psychotic Disorder with Delusions, Hallucinations and Bipolar Disorder. Medical record review of Resident #2's annual MDS dated [DATE] showed a BIMS score of 6 indicating severe cognitive impairment. The resident had verbal behavioral symptoms directed toward others 4 to 6 days, other behavioral symptoms not directed toward others daily, and wandering behaviors daily during the assessment period. Medical record review of Resident #2's Nursing Progress Note dated 10/24/2022 at 3:23 PM showed .resident observed making physical contact with another resident in front hall near lobby. Staff intervened and separated immediately. Resident assessed with no apparent injuries .New orders noted to place resident 1:1 immediately and to send resident out to hospital for further evaluation . During an interview with Resident #1 on 11/7/2022 at 9:05 AM, when asked about the incident he stated .I don't know he just don't like me. He hit me on my back, head, and neck. He hit me with his walker . He stated there had been no exchange of words except he had been sitting at the lobby glass doors and Resident #2 had said 'dude move go on' and Resident #2 got mad when he had to wait for him to move. He stated he was not afraid then or now, he was just staying away from Resident #2. During an interview with the ADON on 11/10/2022 at 8:10 AM, she stated .I entered the initial incident documentation in the URIS [system used by facilities to report required events to the State Survey Agency] system. The 5 day follow up was due on 10/31/2022. I entered the conclusion documentation remotely at approximately 6:00 PM on 10/31/2022. However, there is no record of documentation being received by the state within the required 5-day time frame. When we received the email from Nashville on 11/1/2022 the incident was closed. I never questioned that my submission on 10/31/2022 had not been received or I would have called to see why it wasn't there .We had no idea it had not been received until the DON asked me to print the updated report when you [State Surveyor] asked for it . During an interview with the Administrator on 11/10/2022 at 9:30 AM, he stated .As far as the issue of the failure to provide the 5-day outcome to the state on the 31st the regional director of operations and I spoke. She was asking me about the follow up. I explained to her the ADON was doing the input of that data as I was off work, and I would follow up with the ADON. After that conversation I did just that, I followed up with the ADON and she said she would take care of it. That night I followed up with the ADON and she said it had been reported that afternoon. As to why it is not there, I cannot answer that .

Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to prevent physical abuse for 1 resident (#2) of 5 residents reviewed for abuse. The findings include: Review of the policy titled, Abuse Prevention Program, revised 1/19/2017, showed .it is the policy of this facility to prevent resident abuse, neglect, mistreatment .hitting, slapping, pinching, kicking, etc .will not tolerate resident abuse or treatment by anyone, including staff . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Risk Management Alleged Abuse dated 10/26/2020 at 3:30 AM, revealed .(Licensed Practical Nurse (LPN) #1) was entering room, observed (Certified Nursing Assistant (CNA) #1), with her back to the door, make contact with the resident . Review of a facility investigation witness statement from CNA #1 dated 10/26/2020, not timed, revealed she had Resident #2 on her side to provide care when the resident . started kicking and hitting. She kicked me in my stomach and slapped my face scratching my eye and I struck her on the back with an open hand . Further review of another witness statement revealed LPN #1 .heard yelling .I got to the door first and saw (CNA #1) standing with her back to me and I saw her make contact with the resident . Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #2 scored a '99' on the Brief Interview of Mental Status (BIMS) indicating the resident was unable to complete the interview. The MDS showed Resident #2 exhibited physical behavior symptoms directed toward others 1 to 3 days and required extensive assistance for toilet use and personal hygiene. Review of the Care Plan for ADL's (Activities of Daily Living), dated 10/28/2020, showed Resident #2 had a self-care deficit related to altered cognition and behavior with assistance with dressing, toileting, and hygiene. An intervention listed revealed . explain all procedures and purpose prior to preforming task .if refuses return when calm . Observation of Resident #1 on 11/3/2020 at 4:30 PM, in her room, revealed an alert, but not interviewable female unable to answer any questions. During a telephone interview with CNA #1 on 11/3/2020 at 5:15 PM, she stated .she kicked me in the stomach and scratched my face .she was incontinent .I rolled her over to the side and she kicked me hard in the stomach, then scratched me .I had an open hand on her back .I was trying to protect myself .it was a reflex .I have cried my eyes out .(LPN #1) came in and pulled me out of the room . During a telephone interview with LPN #1 on 11/3/2020 at 6:00 PM, LPN #1 stated .I heard commotion. I walked in the doorway, both CNA #1 and Resident #2 had their backs to me .I saw CNA #1 bring her arm way back, the resident was laying on her right side. I saw her swing her arm back and hit the resident in the back .I escorted her to the time clock .she said it was a reflex, but she intentionally reflexed with her and it looked intentional . During a telephone interview with Registered Nurse (RN) #1 on 11/4/2020 at 10:05 AM, RN #1 stated she was coming up the hall and heard yelling .(LPN #1) got there first .I heard a slap, real hard, I didn't see it, (LPN ) #1 was in front of me .she (CNA #1) was bleeding from the scratch on her face . it made her mad and that's why she hit her .the scratch was from the brow to the temple . During an interview with the Administrator on 11/4/2020 at 12:45 PM, in the Conference Room, he stated CNA #1 was immediately escorted out and placed on administrative leave. He stated CNA #1 did strike Resident #1 and the abuse of Resident #1 had occurred in the facility.

Based on review of a facility policy, medical record review, and interviews, the facility failed to report an injury of unknown injury involving bodily injury for 1 resident (#1) of 3 residents reviewed for injuries of unknown origin. The findings include: Review of facility policy Abuse Prevention Policy Updated 1/19/17 revealed .All personnel must promptly report any incident of resident abuse, mistreatment or neglect, including injuries of unknown origin .when the source of the injury was not observed or known by any person . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed Resident #1 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status. Medical record review of a nursing progress note dated 5/27/19 at 3:16 PM revealed .c/o (complains of) increased pain to right hip .(named physician) informed .received a new order to obtain right hip x-ray . Medical record review of a Mobile Radiology Report dated 5/27/19 revealed .There is a right hip hemiarthroplasty in normal position. A moderately displaced [MEDICAL CONDITION] trochanter is present. Surgical staples are present in the proximal right thigh laterally. No other fracture dislocation or other abnormalities of the right hip are present .Conclusion .Displaced [MEDICAL CONDITION] trochanter, new . Interview with Licensed Practical Nurse (LPN) #2 on 6/10/19 at 4:20 PM, in the conference room, revealed .on 5/27/19 she (Resident #1) started having some hip pain even with her PRN (as needed) medication .she had started to complain of pain in her hip, her medication was not as effective as it had been. I called the doctor and told him and he ordered a right hip x-ray .I am not aware of anything out of the ordinary occurring, the only thing different was an increased complaint of pain. No one reported anything from any shift (increased pain or injury) . Telephone interview with LPN #2 on 6/11/19 at 9:40 AM revealed .when I came in on the 27th around 6:30 PM .(LPN #1) reported .(Resident #1) had complained of increased pain and the x-ray technician was here .I picked up the x-ray results off the fax early on the 28th and passed them to the day shift nurse .during the night she never complained of pain .and there weren't any non-verbal signs of pain or any discomfort .I am not aware of anything happening, any incidents or a fall that would have attributed to the fracture. I know now I should have checked the fax machine and reported the results immediately . Interview with the Director of Nursing (DON) on 6/11/19 at 11:25 AM, in the conference room, revealed .on Tuesday morning about 10:30 AM, I was notified of the x-ray results of a lesser trochanter fracture on (Resident #1's) right side. I immediately started an investigation .during the interviews with staff no one was aware of any incidents or occurrences that would have attributed to a fracture. I was not able to identify anything indicating abuse/neglect or concerns related to quality of care . Continued interview confirmed the x-ray was obtained at approximately 6:30 PM on 5/27/19 and the x-ray report was faxed to the facility on [DATE] at approximately 7:00 AM. Further interview revealed the DON was notified of the results at approximately 10:30 AM and .I should have been notified immediately when the results were reviewed by the nurse at 7:00 AM . Continued interview confirmed the facility failed to report an injury of unknown origin timely to the State survey agency and the facility failed to follow facility policy.

Based on facility policy review, medical record review, and interview the facility failed to ensure a new falls intervention was implemented after a fall for 1 resident (#28) of 3 residents reviewed for accidents of 30 sampled residents. The findings include: Review of the facility policy, Incidents/Accidents/Falls, undated revealed .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved .All falls will have a site investigation by appropriate staff .Each fall needs a new intervention rolled out . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance for bed mobility, dressing, tranfers and toileting. Medical record review of facility documentation dated 2/9/18, revealed .Pt (patient) hit the emergency light in bathroom; had ambulated w/o (without) calling for assistace .pt was on her knees on the floor .negative for any new injuries . Medical record review of the care plan revealed .2/8/18 fall in room. No injuries . Continued review revealed no new intervention was implemented after the fall on 2/8/18. Interview with the Assistant Director of Nursing on 9/6/18 at 9:00 AM, in the conference room, confirmed the facility failed to follow their policy and failed to implement a new intervention to prevent further falls for Resident #28.

Based on facility policy review, medical record review and interview the facility failed to ensure a resident was reevaluated by a Registered Dietician (RD) after a significant change for 1 resident (#28) reviewed for nutrition of 30 sampled residents. The findings include: Review of the facility policy,Screening and Initial Evaluation, undated revealed . A nutritional assessment is completed at least annually .New admits, Annuals and those Resident's with significant changes will be placed on the list for the RD (Registered Dietician) to see on their next visit. The Registered Dietician will review the assessment completed by the DM (Dietary Manager), and complete an in depth nutritional assessment upon admission or significant change would warrant an in depth assessment sooner. Any other resident who is deemed high risk such as those with .[MEDICAL TREATMENT] .will be placed on the list for the RD to review at their next visit .A quarterly note will be entered into the health record by the Dining Services Manager (Dietary Manager) .no less that quarterly .The care plan will be updated as changes are made in nutritional interventions as they occur . Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact, had a weight loss of 5% or more and was receiving [MEDICAL TREATMENT]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Medical record review of the resident's weight dated 11/3/17 (previous admission) revealed a weight of 122 pounds (lbs). Continued review revealed a readmission weight on 12/23/17 was 92.2 lbs (a decrease of 29.8 lbs) Medical record review of a Registered Dietician assessment dated [DATE] revealed .Screening Factors from MDS .Below desired weight range .Poor intake/Potential < (less than) 75% .Hx (history of) Weight Loss .DX (diagnoses) of Malnutrition .Nutritional Problem #1 .Inadequate oral intake rt (related to) clinical status and dx of anorexia .variable PO (by mouth) intakes of 0-75% not meeting est. (estimated) needs .Nutritional Problem #2 .Need for increased kcal (food calories)/protein consumption rt [MEDICAL TREATMENT] resident and open wounds . Medical record review of a RD progress noted dated 12/28/17 revealed .New Re-Admit .with [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]), dysphagia .anorexia, dehydration, N/V (nausea/vomiting) .CBW (current body weight) 92.2 # (pounds) .BMI .16.9 (suboptimal for age/clinical status) .Ideal body wt (weight) .115# . Medical record review of a Physicians order dated 1/8/18 revealed an order to admit for Resident #28 for hospice services. Medical record review of a Hospice note dated 2/9/18 revealed discontinue weights per hospice for comfort. Interview with the Director of Food Services (Dietary Manager) on 9/6/18 at 10:00 AM, outside the kitchen, confirmed he was not aware until recently that he was responsible for documenting quarterly notes on residents. Continued interview confirmed he did not complete any quarterly notes on Resident #28. Interview with the Director of Nursing on 9/6/18 at 1:30 PM, in the conference room confirmed the facility failed to follow their policy and failed to ensure Resident #28 was re-evaluated quarterly by the RD and Director of Food Services.

Based on observation and interview, the facility failed to ensure expired blood collection tubes were properly disposed of in 1 of 1 storage rooms. The findings include: Observation of the A hall storage room, with Registered Nurse (RN) #1, on [DATE], at 12:05 PM, revealed the following: 97 expired blue top blood collection tubes expired [DATE]. Interview with RN #1, on [DATE], at 12:06 PM, in the A hall storage room confirmed the blood collection tubes were expired and available for resident use.

Based on facility policy review, observation, and interview, the facility failed to maintain the dish machine to ensure dishes were sanitized; failed to properly sanitize dishes in the 3 compartment sink; failed to maintain kitchen equipment and floors in a clean and sanitary manner; and failed to properly store and label dry foods and refrigerated food items, affecting 84 of 87 residents on census. The findings included Review of the facility policy Dishwashing: Machine dated 2017 revealed .The Dining Services staff shall maintain the operation of the dish machine according to established procedure and manufacturer guidelines .to ensure effective cleaning and sanitizing .if the dish machine cannot be repaired in a timely manner, the facility will utilize manual dishwashing procedure . Review of the facility policy Sanitation Solution dated 2017 revealed .Bleach may be used as a sanitizer when prepared according to the following guidelines .1 Tablespoon bleach + l gallon of water . Review of the facility policy Cleaning Rotation dated 2017 revealed .Equipment and utensils will be cleaned .Items cleaned after each use: .Can opener .Work tables and counters .Items cleaned daily: Stove top .Microwave oven .Kitchen and dining room floors .Items cleaned monthly .Ice machines . Review of the facility policy Storing Utensils, Tableware, and Equipment dated 2017 revealed .Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination . Review of the facility policy Food Storage dated 2017 revealed .Label all food items. The label must include the name of the food and the date by which it should be sold, consumed, or discarded .Dry storage guidelines to be followed .store dry food on shelves .six inches off the floor . Review of the facility policy Labeling and Dating of Foods dated 2017 .All foods stored will be properly labeled and dated .all ready to eat foods .will be re-dated with the date the item was opened and a use by date . Review of the facility policy Dishwashing: Manual dated 2017 revealed .QAC (Quaternary Ammonium) typically 200-400 PPM .The concentration of chemical or hot water will be tested before cleaning .and recorded on the three compartment sink log sheet .The pots and pans will be drained and air-dried . Observation on 2/12/18 at 9:00 AM, with the Certified Dietary Manager (CDM), in the kitchen revealed the following A. The steamer with dried debris on the interior sides and bottom, and on the outside handle. B. 3 of 3 work tables with dried and flaky debris on the top work area, and the bottom storage areas. C. Juice Machine with dried sticky debris on the base of the machine, and around dispensing spouts. D. Deep Fryer with thick debris on the interior sides, and splash guard, also food particles from the day prior in a fryer basket. E. Stove top and burners with various types of thick dried and burnt debris. F. Ice Machine with dark pink slimy debris on the spill guard and inside of the door. G. Microwave with dried debris on the interior top, sides, carousel, and bottom. H. Can Opener with dried debris on the blade and base I. Cutlery Rack with dried, and sticky debris on the top and knife storage slots. J. Kitchen floor had multiple areas of dried food/beverage debris, and small particles paper. Continued observation with the CDM, in the dish room revealed a low temperature dish machine. Further Observation revealed the machine was not dispensing sanitizer into the sanitizing cycle in 3 of 3 cycles observed. Interview on 2/12/18 at 9:15 AM, with the CDM revealed the dishes would be washed and sanitized in the 3 compartment sink, and no dishware had been returned to the kitchen for usage. Observation on 2/12/18 at 9:17 AM, with the CDM, in the kitchen revealed the following items available for resident consumption: A. 5# bag of oats approximately ¾ full, open to air, and no label with an open date or use by date. B. 1# bag of dry gravy mix approximately ½ full, open to air, and no label with an open date or use by date. C. 10# box of Elf Graham crackers approximately ½ full open and on the floor. Further observation with the CDM, of a reach in cooler revealed the following beverages available for resident consumption A. 12 four ounce bowls with canned pears with no label or use by date. B. 10 eight ounce glasses with various beverages with no label or use by date. C. 6 one quart decanters filled with no label or use by date. Further observation of the kitchen with the CDM revealed A. 2 of 12 two inch quarter steam table pans stored wet, and with dried food debris. B. 2 of 5 4 inch quarter steam table pans stored wet, and with dried food debris. Interview on 2/12/18 at 9:40 AM, with the CDM, confirmed the facility failed to maintain the dish machine to ensure proper sanitation of dishes, and failed to maintain clean and sanitary kitchen equipment, utensils, and floors. Further interview confirmed the facility failed to properly store and label foods in the dry storage area and in 2 of 2 reach in coolers. Observation on 2/12/18 at 10:05 AM, with the CDM in the kitchen revealed 2 dietary employees washing dishes in the 3 compartment sink. Further observation revealed no sanitizer testing strips were available to use. Interview on 2/12/18 at 10:08 AM, with the Cook confirmed she had not tested the sanitizer solution in the three compartment sink prior to washing dishes.

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 (Resident #2) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Program Updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #9 revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Continued review revealed the resident exhibited no behaviors during the review period. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] for Resident #2 revealed the resident was rarely/never understood. Continued review revealed no behaviors were exhibited during the review period. Observation on 2/12/18 at 10:25 AM, of Resident #2, in her room on the secure unit revealed the resident seated on the side of her bed. Continued observation revealed the resident was awake and alert, however did not answer questions appropriately. Review of the facility investigation dated 1/19/18 revealed .At 12:53 PM (Resident #2) was struck four times on the left shoulder by (Resident #9) after she wondered into his room .Upon attempting to enter (resident #9's) room, she (Resident #2) backed out; he followed her out, and then struck her four times on the left shoulder with an open hand . Review of a Progress Note dated 1/19/18 at 3:06 PM, for (Resident #3) revealed .Resident opened door to (Resident #9's) room attempting to enter. Resident began backing out of room at which time (Resident #9) struck 3-4 times making contact to left shoulder . Interview on 2/14/18 at 12:00 PM, with(NAME)Lowhorn DON, in the conference room confirmed Resident #9, did willfully hit Resident #2 in attempt to remove her from his room, and the facility failed to prevent abuse for one resident #2.

Based on medical record review, observations and interviews, the facility failed to honor 1 resident's (#62) preferences for grooming services, identified through 1 of 3 family interviews conducted, of 35 residents sampled. This failure resulted in Harm to Resident #62. The findings included: Medical record review of Resident #62's History and Physical dated 12/28/15 revealed Resident #62 was a [AGE] year-old male with a past medical history of [REDACTED]. The history further revealed the resident was immobile, with [DIAGNOSES REDACTED]. A review of Resident #62's Physician's Progress Note dated 4/13/17 indicated the resident's judgement/insight was appropriate. The note indicated the resident communicated by pointing and shaking his head yes or no. Review of the most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident required extensive assistance and was dependent on 1-2 staff for bed mobility, transfers, toilet use, dressing, and personal hygiene. Under the section titled E0800: Rejection of Care - Presence & Frequency Resident #62 was coded as .behavior not exhibited. Continued review revealed a staff assessment for mental status was conducted, and the resident had no problems with short or long term memory, was able to recall the current season, location of his room, names and faces of staff members and that he is in a nursing home. Observations on 6/19/17 at 11:42 AM, 6/19/17 at 2:51 PM, 6/19/17 at 4:53 PM, and 6/20/17 at 8:13 AM, revealed Resident #62 in his room lying in bed. Resident #62 had facial hair (whiskers) noted on his face and his hair was unkempt and had not been combed. Continued observation revealed the resident was wearing a gown with brown stains around the front chest area in 3 of the observations. A family interview on 6/20/17 at 9:35 AM with Family Member #1, revealed the family member was very concerned about Resident #62 not receiving his showers as scheduled. The family member said the issue seemed to be affecting Resident #62. Family Member #1 indicated Resident #62 was sad and unhappy about his (unkempt) appearance. Family Member #1 also stated Resident #62 had gone 10 days without having a shower, and it bothered the resident greatly. The family member reported this (no baths and unkempt appearance) had happened several times with the resident going for long stretches of not being showered for 7 days or more. According to the family member, prior to his [MEDICAL CONDITION], Resident #62 always took pride in his appearance and his daily grooming or lack thereof as a major concern. Family Member #1 stated the nurses had been told about it but the problem continued to occur. Observation on 6/20/2017 at 12:45:PM Resident #62 observed awake, sitting up in bed watching TV, unshaven with long facial whiskers, hair unkempt with multiple white flakes, eyes with crusty substance in corners, and gown had tan stains on front chest area. Resident was non-verbal. Easily understands others and is easily understood, as resident is able to nod head to respond Yes or No. When asked if he had a shower on Saturday, 3 - 4 days ago, resident responded, No by nodding his head. Asked resident has it been 10 days or more since he last had a shower? Resident nodded his head to respond, Yes. Asked resident if he had refused to shower in the last 10 days, resident adamantly shook his head, No. Asked resident how does it make you feel when you haven't had a shower in 10 days? Resident responded with sad facial expression with watery substance welling in eyes. Asked resident if it was his preference to receive his showers at minimum twice a week on Wednesdays and Saturdays as scheduled? Resident smiled and nodded, Yes. An interview was conducted with CNA #2 (Shower Tech) on 6/20/17 at 1:06 PM. CNA #2 stated Resident #62 loved his showers and rarely refused them. CNA #2 said Resident #62 may miss a shower if he was out on a family visit. She said he has refused nailcare once or twice Review of POC (plan of care) Response History Report dated from 5/25/17 - 6/20/17 indicated the resident last received a shower on 6/10/17, approximately 10 consecutive days. Continued review revealed from 5/25/17 - 6/2/17 Resident #62 did not receive a shower for 9 consecutive days. Interview with the Assistant Director of Nursing on 6/20/17 at 4:02 PM, revealed the resident was scheduled to receive a shower on Wednesdays and Saturdays. She reviewed the CNA's activities of daily living (ADL) documentation for baths and showers for the past 30 days and confirmed the resident's last shower was on 6/10/17. Continued interview confirmed each resident is scheduled to have at least 2 showers per week, with bed baths to supplement in between during AM (morning) care and it is not acceptable for a resident to go 10 days without a shower.

Based on medical record review, observations and interviews, the facility failed to provide the necessary assistance to maintain personal hygiene and grooming preferences for 1 resident (#62) of 34 residents reviewed. This failure resulted in Harm for Resident #62. The findings included: Medical record review of Resident #62's History and Physical, dated 12/28/15 revealed Resident #62 was a [AGE] year-old male with a past medical history of [REDACTED]. The history further revealed the resident was immobile, with [DIAGNOSES REDACTED]. Review of Resident #62's Physician's Progress Note dated 4/13/17, indicated the resident's judgement/insight was appropriate. The note indicated the resident communicated by pointing and shaking his head yes or no. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident required extensive assistance and was dependent on 1-2 staff for bed mobility, transfers, toilet use, dressing, and personal hygiene. Under the section titled E0800: Rejection of Care - Presence & Frequency Resident #62 was coded as .behavior not exhibited. Continued review revealed a staff assessment for mental status was conducted, showing the resident had no problems with short or long term memory, was able to recall the current season, location of his room, names and faces of staff members and that he is in a nursing home. Observations on 6/19/17 at 11:42 AM, 6/19/17 at 2:51 PM, 6/19/17 at 4:53 PM, and 6/20/17 at 8:13 AM, revealed Resident #62 in his room lying in bed. Resident #62 had facial hair (whiskers) noted on his face and during each observation his hair was unkempt and had not been combed. Continued observation revealed the gown he was wearing, for the 3 observations, contained small brown stains around the front chest area. A family interview was conducted on 6/20/17 at 9:35 AM with Family Member #1, who stated, he/she was very concerned about Resident #62 not receiving his showers as scheduled. Continued interview revealed Resident #62 had gone 10 days without having a shower. The family member reported this (no baths and unkempt appearance) had happened several times that the resident gone for long stretches of not being showered for 7 days or more. Observation on 6/20/2017 at 12:45 PM resident observed awake, sitting up in bed watching TV, unshaven with long facial whiskers, hair unkempt with multiple white flakes, eyes with crusty substance in corners, and gown has tan stains on front chest area. Resident is non-verbal. Easily understands others and is easily understood, as resident is able to nod head to respond Yes or No. When asked if he had a shower on Saturday, 3 - 4 days ago, resident responded, No by nodding his head. Asked resident has it been 10 days or more since he last had a shower? Resident nodded his head to respond, Yes. Asked resident if he had refused to shower in the last 10 days, resident adamantly shook his head, No. An interview was conducted with CNA #2 (Shower Tech) on 6/20/17 at 1:06 PM. CNA #2 stated, she worked day shift and performed all the scheduled showers during the day. She said she shampooed the hair, shaved them, and cut residents' fingernails. She said she does not chart or keep a log of who received a shower and what care was given. According to CNA #2, . the assigned floor (nurse aides) CNAs do that. She further stated, Resident #62 loved his showers and rarely refused them. CNA #2 said Resident #62 may miss a shower if he was out on a family visit. She said he has refused nailcare once or twice Review of POC (plan of care) Response History Report dated from 5/25/17 - 6/20/17 indicated the resident last received a shower on 6/10/17, approximately 10 consecutive days. From 5/25/17 - 6/2/17 Resident #62 did not receive a shower for 9 consecutive days. Interview with the Assisstant Director of Nursing on 6/20/17 at 4:02 PM, revealed the resident was scheduled to receive a shower on Wednesdays and Saturdays. She reviewed the CNA activities of daily living (ADL) documentation for baths and showers for the past 30 days and confirmed the resident's last shower was on 6/10/17.

Based on facility policy review, observation, and interview the facility failed to: 1) Maintain the dish machine's wash and rinse cycle temperatures, and the sanitizing chemical parts per million (PPM) levels at the manufacturer's recommended specifications potentially affecting 86 residents who receive plated meals, and 2) Failed to maintain food temperatures on the main dining room steam table in accordance with food service guidelines affecting 6 residents confirmed to have received meals from the steam table. The findings included: Review of the facility's policy, Dish Machine Use and Care not dated, revealed, The Maintenance department should check and record the internal dish machine temperatures at least once per week with a non-mercury thermometer or test strips. Review of facility's policy, Dishwashing Machine, dated 2017 revealed the following: Check the machine each morning before any dishes are washed, and again after each meal before dishes are washed. If the dishwasher has not been used for several hours, it is recommended to (sic) allow the machine to run for a cycle or two to allow the dishwasher to reach proper function. Check to ensure that the wash and rinse cycles are achieving proper temperature per manufacture (sic) guidelines. If a chemical sanitizer is used, check the concentration using the correct test strip. Record wash/rinse temperatures and sanitizer concentration if used on the dish machine log before any dishes are washed. Refer to the guidelines on the dish machine log for acceptable temperatures and sanitizer concentrations for high and low temperature dish machines. If not at the correct hot water temperature, or the proper sanitizing concentration, do not proceed to wash dishes. Corrective action must be taken. Review of facility's policy attachment, Dishwasher Temperature Log dated 2017 revealed, Low Temperature Dish Machine must be at least 120 degrees F (Fahrenheit) Wash, 50-100 PPM Hypochlorite (sanitizing solution). 1. During observations on 6/19/2017 at 8:46 AM, in the kitchen, Dishwasher #1 was observed rinsing dirty dishes (plates, glasses, and trays) and preparing additional trays for washing in the Low Temperature (Temp) Hobart (AM Select) Dishwasher. During the observation two trays of wet dishes (plates) were sitting on the completed rack. Dishwasher #1 was asked, how and when the dish machine temperature checks were performed and recorded. Dishwasher #1 stated he/she checks the dish machine's temperature each morning by running a few cycles first; then he/she records the last test cycle's wash and rinse temperatures. Dishwasher #1 was requested to run a test cycle to check the dish machine's current wash and rinse temperatures and to demonstrate how he/she performs PPMs to check the amount of sanitizing chemical in the rinse water each day. Dishwasher #1 stated, He/she has been working at the facility for one month and was not aware of when or how to test for proper PPM levels of chemical. Review of manufacturer's information panel on the side of the dish machine revealed: Chemical water specifications: WASH = 120 degrees / Chemical water RINSE = 120 degrees Review of facility posted Dish Machine Temperature Log dated June 2017 revealed no wash or final rinse temperatures were recorded for 6/19/17, of the observed dishwashing process. The PPM for 6/19/17 was logged as 100 and signed with initials by Dishwasher #1. Dishwasher #1 stated the 6/19/17 temperatures were done and both wash and rinse cycles were above 120. The June 2017 log also showed ten separate entries signed by Dishwasher #1 for recorded wash temperatures, final rinse temperatures, and PPM readings on 6/04/17, 6/05/17, 6/06/17, 6/11/17, 6/12/17, 6/13/17, 6/16/17 (twice), 6/18/17, and 6/19/17. Dishwasher #1 confirmed the signed initials for the dates as listed and further stated, He/she was not aware of when or how to test for proper PPM levels of chemical. Observation on 6/19/17 at 9:04 AM revealed Dishwasher #1 ran a test cycle revealing the wash cycle temperature was 120 degrees and the rinse cycle temperature was 84. A second test cycle was run at 9:07 AM revealing the wash cycle temperature was 118 degrees and the rinse cycle was 113. At 9:10 AM the Dietary Manager (DM) came into the wash room and ran a test cycle revealing the wash cycle temperature was 120 degrees and the rinse cycle was 87. An interview was conducted with the DM on 6/19/2017 at 9:12 AM. The DM stated she was going to call the Maintenance Director to have him check the water temperatures. She further stated she would prepare to serve lunch on paper items until the water temperatures for the dishwasher and PPM readings could be resolved. The DM stated Dishwasher #1 was hired about one month ago and has been trained, like all staff hired for dishwashing, to check daily dish machine temperatures, chemical sanitizer PPM testing, and how to record findings on the dishwasher temperature logs. DM reviewed Dishwasher #1's training file and was unable to locate documentation of Dishwasher #1's training on the dish machine chemical sanitizer testing. Observation on 6/19/2017 at 10:10 AM with DM and Cook #1 revealed both present to retest the dishwasher temperatures and PPMs as follows: At 10:12 AM a test cycle was run revealing the wash cycle temperature was 128 degrees Fahrenheit (F) and the rinse cycle was 116 F. At 10:20 AM a test cycle was run revealing the wash cycle temperature was 127 F, and the rinse cycle was 113 F. The PPM was tested 8 - 10 times with Ecolab Precision and Chlorine Strips revealing 0 PPM level with each final rinse test. The chemical tubing was inspected during the wash and rinse cycles by the DM, who acknowledged she was unable to see chemicals flowing through tubing. At 10:45 AM, the DM stated she called the food service contractor who performed monthly maintenance checks and asked him to come and check out the machine. An interview was conducted with the DM on 6/19/2017 at 2:30 PM, who revealed the subcontractor for the dishwasher maintenance came to the facility at 1:40 PM. She said he tested the dishwasher PPM levels with his own chlorine test strips four times, and the PPM showed zero. He then primed the chemical tubes and retested it and the PPM was at 100. Continued interview confirmed the rinse cycle repeatedly showed readings at 118 or below. The Maintenance Director was present and left to go turn the water heater up. After waiting a few minutes, the subcontractor repeated the wash and rinse temperatures and they were 124 (wash) and 121 (rinse). The DM said the subcontractor provided the appropriate strips, to use on the facility's machine. Interview conducted with Maintenance Director on 6/21/2017 at 11:52 AM who stated he could not find his weekly temperature logs for the facility. He stated he would check the water faucet temperatures in the kitchen on a weekly basis as this was included in his entire facility weekly temperature checks. He provided a handwritten copy of quarterly dish machine temperature checks performed by maintenance. He confirmed he was not performing weekly internal dish machine temperature checks as stated in policy. He stated the dish machine has a designated water heater and it was turned up from 130 to 150 degrees on Monday, 6/19/17. 2. Observation on 6/19/2017 at 11:40 AM revealed the steam table temperatures were completed in the kitchen prior to meal distribution by Cook #2 as follows: Carrots - 157, Barbecue (BBQ) pork -167, ground BBQ Pork 175, Tater Tots 181, green bean 182, Pureed green beans 193. During observations on 6/19/2017 at 12:12 PM, the steam table temperatures were measured in the main dining room by Cook #2 as follows: Carrots - 186, Mashed Potatoes - 143, Pureed green beans - 141, (Barbeque) BBQ pork (Ground) -121, BBQ pork (Pureed) -135. Observation at 12:17 PM revealed Cook #1 left the steam table to report findings to the Dietary Manager. Continued observation revealed the food remained covered on the steam table awaiting reheat and the Dietary Manager's notification. Interview at 12:22 PM with the DM in the kitchen regarding Cook #1 leaving the steam table to notify the DM of reported low temperatures for BBQ pork, revealed the DM was not aware and she would tell Cook #1 to pull the BBQ off the steam table and reheat it. Observation in the main dining room at 12:27 revealed Cook #1 had plated and served the pureed and ground BBQ pork to 6 residents who required assistance with feeding from staff. All 6 residents had consumed more than one to three table spoons of the BBQ pork. The 6 residents' identities were given to the DM. Interview conducted with Cook #1 on 6/19/2017 at 2:25 PM confirmed she was aware the steam table temperature for the BBQ pork (Pureed and Ground) was below the acceptable range temperatures. She stated she immediately left to tell the dietary manager of her findings and was stopped by a staff member to ask to do something else and she forgot. Cook #1 further stated upon return to the steam table she commenced to prepare the plates with the BBQ pork without reheating. During an interview with the DM, she stated the cook should have informed her immediately, pulled the BBQ pork immediately, and reheated it until it was at an acceptable level. She said she liked a 165 (degrees Fahrenheit) or above for all her meats.

Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#80) of 4 residents reviewed for weight loss, of 34 residents reviewed. The findings included: Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated 6/1/17 revealed XXX[AGE] year-old .female, who comes to the hospital because of severe swelling all over, shortness of breath (SOB) .She was known to have jugular venous distention, bilateral [MEDICAL CONDITION] .She had been recently admitted 9 days prior from .a fall where she had rib fracture and the effusion in her chest has apparently worsened .Exertion makes her shortness of breath worse, rest and oxygen makes it better .Impression: 1. [MEDICAL CONDITION] . Medical record review of a physician's order dated 6/2/17 revealed Daily weights for [MEDICAL CONDITIONS] in the morning . Medical record review of the Weights and Vitals Summary revealed the following: on 6/6/17 weight recorded as 223 lbs. (pounds) via wheelchair; on 6/7/17 weight recorded as 220.4 lbs. via mechanical lift; on 6/8/17 weight recorded as 220.4 lbs. via wheelchair; on 6/10/17 weight recorded as 212.4 lbs. via mechanical lift; on 6/11/17 weight recorded as 207 lbs. via mechanical lift; on 6/12/17 weight recorded as 203.6 lbs. standing; on 6/13/17 weight recorded as 198.6 lbs. via mechanical lift; on 6/14/17 weight recorded as 197 lbs. via mechanical lift; on 6/17/17 weight recorded as 197 via bedscale; and on 6/20/17 weight recorded as 165.4 lbs. via mechanical lift. Medical record review of a nursing note dated 6/8/17 revealed Assessment: Resident cont (continues) to have +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities), crackles to lower ls (?lungs), Dr .notified, new order for [MEDICATION NAME] 80mg bid (twice a day), Potassium 20 meq bid, Resident alert with confusion at times, able to make needs known .Resp (respirations) even non labored, SOB noted when laying flat .HOB (head of bed) elevated .poor appetite noted this shift . Observation on 6/20/17 at 12:40 PM revealed the resident lying on the bed with the HOB elevated with the spouse at bedside. Interview with the Director of Nursing (DON) on 6/20/17 at 4:20 PM, in the DON's office revealed 1 of the weights obtained on 6/17/17 or 6/20/17 was not accurate and the weight on 6/17/17 was documented as being obtained via a bedscale was not accurate because the facility did not have a bedscale. Continued interview revealed the Restorative Aide did all the weights in the facility when she was working. Further interview revealed the same type of scale needed to be used consistently, and if a different scale needed to be used for individual residents a reason for the change in the type of scale used needed to be documented. Further interview confirmed daily weights were not obtained for Resident #80 on the following dates: 6/3/17, 6/4/17, 6/5/17, 6/9/17, 6/15/17, 6/16/17, 6/18/17, and 6/19/17 (8 of 18 opportunities from 6/3/17-6/20/17).

Based on review of facility policy, review of the trial balance for resident trust funds, and interview, the facility failed to make trust funds available on the week-end for 1 resident (#78) of 15 residents interviewed. The findings included: Review of the facility policy titled, Resident Trust issued: 10/20/15, included under the section: Procedure, numbered 1 through 12. Review of procedure 6. Banking Times will be posted and access to resident funds will be available on Saturday and Sunday during banking hours. Those residents wishing to withdraw or deposit money may do so at these times. Observation on entrance revealed there was no posting of banking hours on 6/19/17 or on 6/20/17. Interview of Resident #78, on 6/19/17 at 4:19 PM, revealed he does have a personal funds account with the facility. Resident #78 stated he is not able to withdraw funds from his account on the week-ends. You can only get money when the business office is open and she works Monday thru Friday. A sign posted on 6/21/17 outside the door of the business office included the following information: Resident Trust Banking Hours Monday through Friday from 9am to 5pm Interview of Business Office Manager (BOM), at 7:45 a.m. on 6/21/17, verified the residents had no access to funds on Week-ends. We have nothing in writing or posted in regards to time to access funds from personal accounts. The BOM stated she was aware that residents should have access to funds on the week-ends but she just hadn't implemented a program.

Based on medical record review, review of staffing schedules and hours, review of a facility job description, review of a facility employee handbook, facility policy review, review of the facility falls investigations, observation and interview, the facility failed to provide sufficient direct care staffing (Licensed Nurses and Certified Nurse Assistants (CNAs) to ensure adequate supervision and protection from falls for five residents (#28, #111, #45, #94, #112) of fourteen residents reviewed on the Alzheimer Care Unit (ACU). The facility's failure to provide sufficient direct care staff for supervision of wandering residents with high fall risk placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective on [DATE], and is ongoing. The Corporate Director of Clinical Services, the Administrator and the Director of Clinical Services (DCS) were informed of the Immediate Jeopardy on [DATE], at 12:30 p.m., in the Administrator's Office. The findings included: Medical record review and facility record review of five residents (#28, #111, #45, #94 and #112) who had fallen while at the facility, revealed a total of forty-six falls, thirty-three of which were unwitnessed occurring from [DATE] to [DATE]. Review of the ACU, hall D and E, revealed D hall had a capacity of 18 residents; E hall had a capacity of 24 residents. Review of the facility's staffing ratios revealed the normal staffing ratio for 7 a.m. to 7 p.m. was one CNA (direct care staff) per six residents and for 7 p.m. to 7a.m., 1 CNA per nine residents. Review of the facility provided documents revealed the normal staffing pattern was one licensed nurse for each of the two Alzheimer's Units per shift. Review of the ACU census revealed: [DATE]: average (av) census 37.5 [DATE]: av census 37 [DATE]: av census 37 [DATE]: av census 38.5 February 2014: av census 37.4 [DATE]: av census 35 [DATE]-10, 2014: av census 32 Review of staffing hours for the ACU on the dates of the resident's falls from [DATE] to [DATE], punch records, and staff schedules revealed: On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on night shift; E hall had 1.5 CNAs on night shift. On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on night shift; E hall had 1.5 CNAs on night shift. On [DATE], when resident #28 had a witnessed fall, D hall had 1 CNA on night shift; E hall had 1 CNA on night shift. On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on day shift, 1 CNA on night shift; E hall had 2 CNAs on the day shift. On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall had one CNA on night shift. On [DATE], when Resident #111 had an unwitnessed fall, D hall had 1 CNA on day shift, 1 CNA on night shift; E hall had 1.5 CNAs on day shift, 1.25 CNAs on night shift. On [DATE], when resident #111 had an unwitnessed fall, E hall had 1 CNA on night shift. On [DATE], when resident #111 fell ambulating unassisted, D hall had 1 CNA on night shift; E hall had no CNA on night shift. On [DATE], when resident #111 had an unwitnessed fall, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall had 1.5 CNAs on night shift. On [DATE], when resident #45 was left in the ACU dining room and fell unassisted, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall had 1 CNA on night shift. On [DATE], when resident #45 fell in the ACU dining room, D hall had 1 CNA for 3.5 hours of the 12 hour night shift; E hall had 1 CNA on night shift. On [DATE], when resident #45 had an unwitnessed fall, D hall had 1 CNA for night shift; E hall had 1 CNA for 7 hours of the 12 hour night shift. On January 4, 2014, when resident #45 had an unwitnessed fall, D hall had 1 CNA for 10 hours of the 12 hour night shift; E hall had 1 CNA on night shift. On [DATE], when resident #45 had an unwitnessed fall, D hall had 1.5 CNAs for night shift; E hall had 1 CNA for 7 hours of the 12 hour night shift. On February 17, 2014, when resident #45 had an unwitnessed fall, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall 0.5 CNAs for night shift. On [DATE], when resident #95 tried to stand unassisted and fell , D hall had 1 CNA for 7 hours of the 12 hour night shift; E hall had 1 CNA for the night shift. On [DATE], when resident #95 had an unwitnessed fall, D hall had 1.5 CNAs on day shift, 1 CNA on night shift; E hall had 1 CNA on day shift, 1.5 CNAs on night shift. On [DATE], when resident #112 had an unwitnessed fall, D hall had 1 CNA on night shift; E hall had 1 CNA on night shift. On [DATE], when resident #112 had an unwitnessed fall, D hall had 1 CNA for 9 hours of the 12 hour night shift; E hall had 1 CNA for day shift. Review of the facility's corporate description of an "Alzheimer's Care Specialist" duties revealed: "Residents with cognitive impairment require, a more constant staff presence for the implementation of the structured daily plan for each resident in their assignment, the Care Specialist is assigned to the same group of residents each shift, be dedicated only to the ACU and not assigned to other duties in the facility except in an extreme emergency and not as a routine practice, and each resident should have permanently assigned primary caregivers (one for each shift plus a relief worker), and the relief worker is a certified dementia caregiver that floats." Observations from [DATE] to [DATE] and on [DATE], on the D and E halls in the ACU, revealed both halls were staffed with one licensed nurse and one CNA on each hall on day shift. On [DATE], census in the D hall was twelve residents on day shift, one resident, #112 discharged out with family by private vehicle to another facility closer to the family. Census on [DATE], was eleven residents. Resident #111 expired at the facility on [DATE], at 7:30 p.m., leaving ten residents on [DATE]. Census on [DATE], on D hall was ten residents. Interview with the Clinical Director of the Alzheimers Care Unit (ACU) on [DATE], at 8:40 a.m., in the conference room confirmed "more staff needed" in the ACU to monitor residents and to prevent falls. Continued interview confirmed nurses and CNAs on the ACU are trained and responsible for providing activities and the family dining experience (nurses and CNA's sit at table and eat with residents) for all three day shift meals for all residents in addition to their usual nursing care duties. Further interview confirmed "lately staffing has been one nurse and one CNA on each hall, more would be better." Observation and interview with Licensed Practical Nurse (LPN) #2 on [DATE], at 2:30 p.m., in the D hall nurse's station revealed camera monitors in the station for the common areas of the unit, but nurses could only monitor all the common areas if the nurse was sitting in the nurse's station because the common areas included not only the hallway, but included the dining room, the TV room at the end of the hall and a sitting room. Observation and interview with LPN #2, on [DATE], at 9:45 a.m., in the D hall with a sleeping resident (#28) in a Broda chair beside the nurse confirmed staff worked twelve hour shifts except on Mondays when the shifts were split. LPN #2 further confirmed one CNA and one LPN were covering the D hall of the ACU that day with a census of ten residents with severe cognitive impairment, poor safety awareness, and wandering behaviors. LPN #2 confirmed unit nurses were responsible for medication administration; all staff on shift were responsible for providing activities, and supervision of the residents; "baths, dressing, whatever the resident needs" and LPN #2 stated the staff served three meals in the ACU dining room and assisted residents with eating for all three meals. LPN #2 stated when a CNA was bathing a resident the nurse was responsible for monitoring the common areas, redirecting residents, answering call lights and the unit telephone. Continued interview confirmed LPN #2 was providing 1:1 monitoring (in addition to other assigned duties) for resident #28 who had sustained two falls in the last week. Observation in the ACU dining room on E-hall, on [DATE], at 10:00 a.m., revealed twelve residents in the dining room with no staff present. Interview with LPN #6 (float nurse) and CNA #2 on [DATE], at 10:15 a.m., in the E hallway revealed there were no cameras in E hall nurse's station and staff had no unobstructed view of all the common areas on the E hall from the nurse's station. LPN #6 and CNA #2 also confirmed one LPN and one CNA were working that day on E hall, but usually not enough staff with only one nurse and one CNA. Observation on [DATE], at 6:15 p.m., in the D hall sitting room revealed LPN #2 was singing with five residents present. Further observation revealed four residents in the TV room, sleeping in the recliners with the TV on; no supervision in the room and no one in the nursing station to watch the cameras. Interview with CNA #3, on [DATE], at 10:25 a.m., in the shower room on E hall confirmed "...not enough staff when only one CNA and one nurse scheduled." Observation and interview with LPN #3 on [DATE], at 3:55 p.m., in the D hallway revealed LPN #3 sitting at a table in the dining room with four residents (one resident had a wet spot on pants five inches in diameter) doing a drawing activity. LPN #3 confirmed one CNA was at lunch, the other CNA was toileting other residents, and a call light was flashing over one of the room doors, with no one to check the resident in the room. During the interview, LPN #6 (assigned to the E hall) came to the dining room door and announced there were two CNAs on E hall but (LPN #6) was leaving the facility to go to the hospital with a laboratory specimen needing to be tested immediately and stated the D hall nurse, LPN #3, might have to help in the E hall while the nurse was delivering the lab. The E hall nurse left the unit. Review of the facility Employee Handbook dated [DATE], revealed "...You must clock out for meal periods and clock back in when returning to work..." Interview with the Director of Nursing services (DNS) on [DATE], at 10:10 a.m., in the conference room confirmed the ACU unit staffing is calculated differently from the other units and the ACU staffing should be higher than on other units. The DNS stated "available staff scheduled is divided equally between the two ACU halls and also stated that staff does not monitor residents 1:1 anywhere in the building. Continued interview with the DNS confirmed all staff work twelve hour shifts and are required by corporate policy to clock out for a lunch break every full shift worked. The DNS further confirmed that no additional staff was ever sent to cover lunch breaks on the ACU. Interview with the Medical Director (MD), on [DATE], at 11:40 a.m., in the conference room confirmed the facility did not share staffing information with the MD. The MD stated falls had been identified as a problem in the facility "but this is not your garden variety nursing home, it's an Alzheimer's unit, we can't tie them down, we don't want to overmedicate them, and they're going to fall." Interview with CNA #2, on [DATE], at 2:30 p.m., in the E hallway, confirmed not enough staff when one CNA and one nurse is scheduled, "can't do what we need to do for the residents, we usually have eighteen and we can't do all the baths if there's only one CNA, plus one CNA and one nurse can't keep track of the residents, the only way is if one staff member is at one end of the hall and the other staff member at the other end. We really need three, one to be by the dining room and the others at each end of the hall. Sometimes if we do have two CNAs and there's a call in (staff not coming to work) on the long term care halls, they pull from us to cover it." Refer F323K Substandard Quality of Care

Based on facility policy review, medical record review, review of facility falls investigations, observations, and interview, the facility failed to follow policy to revise care plans after every fall for appropriate interventions to prevent further falls for five physically and cognitively impaired residents (#28, #111, #45, #94, #112) of fourteen residents reviewed, who resided in the Alzheimer's Care Unit (ACU). The facility's failure to review and revise residents' care plans, develop, and implement appropriate interventions to prevent falls placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services, were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective on January 13, 2014, and was ongoing. The facility provided an acceptable Allegation of Compliance on April 29, 2014, and a revist on April 30, 2014, and May 1, 2014, revealed the corrective actions implemented on April 29, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F-280 continues at a "E" level citation. The findings included: Review of the facility policy Falls Management Clinical Guidelines, revised 2013, revealed, "...The Interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls...Following resident's fall...Appropriate interventions are implemented...Care plan is updated...Monitoring Compliance The following elements are in place for the center to demonstrate satisfactory compliance with the guide...Residents at risk for falls are care planned with individualized interventions..." Review of facility policy, Fall Risk/Post Fall Assessment Process, not dated revealed, "...Following A Fall...Injury...Review, update care plan & (and) educate/communicate to staff. Complete Post Fall Investigation..." Review of facility policy, Post Fall Investigation Summary Guidelines for Completion, revised 2013 revealed, "...Evaluate for causative factors...Attempt to establish what the resident was doing/attempting to do prior to the fall. Did the resident fail to request assistance...Care Plan Developed/Revised as Indicated: Identify if the care plan was updated and new approaches to be implemented...Recommendations and Interventions Post Fall: Identify any new interventions that will be immediately implemented to reduce the potential for falls to reoccur...Recommendations implemented shall be recorded on the report and plan of care revised as necessary..." Review of a staff in-service, Reducing the Risk of Resident Falls, provided to nursing staff in January 2014 revealed, "...Evaluation of the causal factors leading to a resident fall helps support relevant and consistent interventions, which may help prevent future occurrences...Revising the resident's plan of care and/or facility practices, as needed, to reduce the likelihood of another fall...Fall Reduction Program...The Plan of Care should be reviewed and revised with interventions after each fall, as appropriate...Interdisciplinary Team (IDT) Strategies...Formulate interdisciplinary goals addressing safety. Identify specific strategies in the care plan for reducing the risk of falls...Reporting and Documentation When a resident falls, complete and document the following...Measure to prevent future falls based on the fall assessment. Care plan interventions (include the fall risk assessment score and resident and family/responsible party education). The response to interventions, progress or decline...The IDT will address any corrective action on the plan of care..." Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated December 14, 2013, revealed, "...At risk for falls related to: Use of medication, History of falls, cognitive/communication deficits, assist needed wtih (with) bed mobility/transfers, incontinence, new environment/room...goal I will not have any fall related injuries..." Medical record review of the physician history and physical dated December 19, 2013, revealed, "...is a high fall risk...patient is appropriate for memory unit...fall precautions..." Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #28 had short term memory problem, long term memory problem, and severely impaired cognitive skills for daily decision making. Further review revealed the resident had wandering behavior "daily" and needed supervision (oversight, encouragement or cueing) to walk in room and in corridor; limited assistance (staff provide guided maneuvering) ambulating on unit; balance was not steady, but able to stabilize without staff assistance; and had impairment on both sides for range of motion. Continued review revealed the resident had a fall in the last month prior to admission and a fall in the last 2-6 months prior to admission. Review of the care plan initiated December 14, 2013, revealed "...bed in low position...Call light or personal items available and in easy reach or provide reacher..." Review of a facility investigation dated December 22, 2013, at 1:00 a.m., revealed the resident had an unwitnessed fall. Review of the facility falls investigation revealed "...resident was observed lying on floor beside bed on the left side facing the wall. Resident stated 'I rolled over too far'...call light in reach." Review of the Care Plan revealed no new interventions regarding the fall were updated on the care plan following the December 22, 2013, fall. Review of a facility fall investigation dated January 10, 2014, at 7:15 p.m., revealed the resident had an unwitnessed fall. Review of the facility falls investigation revealed "...resident room...resident was found on floor in front of bed lying on left side..." Interventions on the care plan updated January 10, 2014, included "mat beside bed." Review of a facility fall investigation dated January 13, 2014, at 4:30 p.m., revealed the Resident #28 had a witnessed fall in the dining room. Review of the falls investigation revealed the resident was sitting in the wheelchair (w/c) at the dining table, stood at the table, and fell before staff could get to the resident..." Interventions updated on the care plan January 13, 2014, were "...low chair...MD (physician) to do med (medication) review..." Medical record review of a nursing note dated January 14, 2014, at 6:36 a.m., revealed, "...resident c/o (complain of) pain to back and hip while ambulating. ROM (Range of Motion) intact. Recent fall...new order received for x-ray to bilat (bilateral) hips and back..." Review of the falls investigation and follow-up recommendations for the fall on January 13, 2014, revealed, "...x-ray ordered d/t (due to) c/o pain. Revealed (L) (left) hip fx. (fracture)...MD ordered to send to ER (emergency room ) for eval. (evaluation)..." Review of radiology reports dated January 14, 2014, from a mobile x-ray revealed "Pelvis with bilateral hips...displaced LEFT intertrochanteric (hip) fracture...Lumbar Spine, 2 views...Superior endplate fractures of L2 and L3 (lumbar spine) of uncertain age and etiology..." Medical record review of a nursing note dated January 15, 2014, at 3:15 p.m., revealed, "...resident readmitted ...from (acute care hospital) after being treated for [REDACTED]. Resident was followed by ortho (orthopedic) surgeon and no surgery done d/t age..." Medical record review of the care plan revealed the intervention "low chair" initiated January 13, 2014. (No new interventions after diagnosed with [REDACTED]. Review of a falls investigation dated January 17, 2014, at 11:44 a.m., (four days after fracturing hip from a fall), revealed Resident #28 had an unwitnessed fall in the resident's room. Review of the facility falls investigation revealed, "...ambulating without assistance...at foot of...bed holding...head stating 'my head is bleeding'...decision made to send to (acute care hospital) ER for eval/tx (evaluation and treatment)..." Medical record review of the emergency room physician's order dated January 17, 2014, at 3:15 p.m., revealed, "...accidental fall, scalp laceration, head injury...continue current plan of care...staple removal in 5-7 days...neuro (neurological) checks q2h (every two hours) x (times) 24 h for changes in mental status..." (No new interventions initiated on the care plan for staple removal or wound care.) The facility interventions included, "...bed against wall to open up room, self-releasing belt for w/c (wheelchair), bed alarm while in bed..." Medical record review of a nursing note dated January 17, 2014, at 7:54 p.m., revealed "...self-releasing belt added w/ (with) resident continually removing & (and) attempting to transfer self unassisted..." Medical record review of the nursing notes dated January 18, 2014, at 3:25 p.m., revealed "...self-releasing belt in use as instructed w/resident able to removed (remove) at will...Very unsteady gait..." Medical record review of the nursing notes dated January 19, 2014, at 2:28 p.m., revealed "...resident continues to ambulates (ambulate) unassisted while awake. Seatbelt alarm in place to w/c but resident continuously removes seatbelt and attempts to stand unassisted..." Review of a falls investigation dated February 22, 2014, at 7:29 p.m., revealed Resident #28 had a witnessed fall "...fall from w/c...attempting to self transfer from w/c..." Review of the falls investigation report for the February 22nd fall revealed "...skin tear (about size of dime) noted to R (right) thumb...assessed for injury, s/t (skin tear) noted..." Medical record review of a nursing note dated February 22, 2014, at 10:17 p.m., revealed "...at this time attempting to get oob (out of bed) unassisted and out of w/c also..." Medical record review of a nursing note dated February 24, 2014, at 11:33 a.m., revealed "...continuously trying to stand up...1 on 1 provided by nurse..." (No one on one supervision initiated on the care plan.) Review of a falls investigation dated February 24, 2014, at 11:20 p.m., revealed Resident #28 had an unwitnessed fall "...was found in floor with alarm going off...Alarm in place and toileting offered to pt (patient)." (Interventions that were already in place, not new interventions). Review of the falls investigation, care plan, and physician orders revealed no new interventions to prevent further falls were put in place after the fall on February 24, 2014. Medical record review of a nursing note dated February 26, 2014, at 11:33 p.m., revealed "...attempting to get out of bed and wheelchair unassisted..." Review of a falls investigation dated February 28, 2014, at 12:10 a.m., revealed Resident #28 had an unwitnessed fall "...Resident in bed when pressure alarm sounded..." Recommendations/Interventions after management review included "...Resident moved to a room closer to nurses (nurse's) station..." (Pressure alarm was not care planned for bed or chair.) Review of a nursing note dated March 1, 2014, at 10:31 a.m., revealed "...resident moved...to be closer to NS (nurse's station)..." Medical record review of a nursing note dated March 5, 2014, at 1:06 p.m., revealed "...resident up in Broda chair (a type of wheelchair with expanded foot rests; chair can be reclined or tilted, like a recliner) for periods throughout the day..." (Broda chair was initiated on the care plan on March 19, 2014.) Medical record review of a nursing note dated March 8, 2014, at 10:40 p.m., revealed "...resident attempted to get oob unassisted twice this shift..." Review of a falls investigation dated March 12, 2014, at 10:15 a.m., revealed Resident #28 had an unwitnessed fall in the dining room,"resident resting in Borda (Broda) chair in dining room...injury: reddened area: head...CNA (Certified Nurse Aide)found resident laying on right side infront (in front) of Broda chair flipped forward...redness noted to right side of head; neuro checks initiated...Recommendations/Interventions taken included...resident assisted to bed...Recommendation/Interventions taken after review included rest periods after meals..." Review of the care plan updated March 12, 2014, revealed "...lay resident down for rest periods after meals..." Review of a falls investigation dated March 19, 2014, at 7:00 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on left side on bedside mat beside bed, injuries: abrasion: eye (left), skin tear: arm (left)...resident stated 'I want to get up'...Recommendations/Interventions include...get resident up in am (morning)...get up in am assist to DR (dining room) for AM meal..." Review of the falls investigation revealed no cause for the fall or for the abrasion to left eye and skin tear to left arm were identified. (Getting residents up for morning meal is a standard of care not an intervention.) Review of the care plan updated March 19, 2014, revealed "...get resident up to broda chair in am..." (Broda chair had previously been flipped forward by the resident attempting to sit up at foot of chair on February 12, 2014). Review of a nursing note dated March 21, 2014, at 8:30 p.m., revealed the resident had an unwitnessed fall "I just wanted up." Facility record review revealed no investigation for the March 21st fall. Medical record review of the care plan revealed no new interventions to prevent further falls were implemented after the fall on March 21, 2014. Medical record review of a nursing note dated March 27, 2014, at 8:20 p.m., revealed "...resident attempting to get oob unassisted several times..." Medical record review of a falls investigation dated April 1, 2014, at 9:45 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on right side in floor beside bed, injury: laceration: head...sent to (acute care hospital) ER for eval..." Review of the facility interventions revealed bedside table and furniture was removed from the resident's bedside. Medical record review of a nursing note dated April 1, 2014, at 1:31 p.m., revealed the resident retuned to the facility from the ER with surgical glue applied to a laceration above the right eye. Medical record review of a nursing note dated April 1, 2014, at 3:04 p.m., revealed "...attempting to get out of Broda chair..." Medical record review of the nursing notes dated April 3, 2014, at 11:24 p.m., revealed "...resident alert trying to climb out of recliner..." Medical record review of a nursing note dated April 4, 2014, at 1:31 a.m., revealed "...resident remains awake one on one watch to prevent falls..." (No one on one supervision initiated on the care plan.) Review of a falls investigation dated April 5, 2014, at 6:50 p.m., revealed Resident #28 had an unwitnessed fall "...resident noted on floor in front of...geri chair in dining room...injuries: hematoma: head, skin tear: hand (right)...resident taken to hospital...noted lying on floor in dining room in front of...gerichair...Review of the facility fall investigation revealed interventions included "...1. Received verbal to send to (acute care hospital) ER for eval/tx (evaluation and treatment) 2. Received verbal (order) to obtain consult w/ (gero-psych hospital) for possible placement 3. Monitor s/t for any s/s (signs or symptoms) infection until area resolvese (resolves) 4. Continue neuro checks per facility protocol 5. MD (physician), RP (responsible party), and DNS (Director of Nursing Service) notified..." Interventions after review included "...hospice made medication changes, geri-psych consult ordered..." Review of a nursing note dated April 5, 2014, at 6:50 p.m., revealed "...fall from geri chair in dining hall just after pm (evening) meal intake...this writer assisted resident w/pm meal w/100% (percent) intake noted. Placed by window in dining hall to aide w/clean up of tables/dishware. (interventions on care plan implemented after fall March 12, 2014, resident was to lay down after meals). Other staff down hall assisting other resident, this writer turned to get med (medication) for this resident when this writer heard noise. Upon turning, this resident noted to be on floor...Neuro checks...per facility protocol r/t (related to) unwitnessed fall...received verbal to send to (acute care hospital) ER for eval/tx r/t hematoma noted to forehead, get (geri-psych) consult on Monday 4/7/14..." Review of physician orders, nursing notes and the care plan revealed the only interventions implemented were increasing residents antianxiety and pain medication; no other safety measures were implemented while awaiting the geri-psych consult. Review of the resident's care plan revealed no interventions related to wandering behaviors. Observation and interview with LPN #2 on April 7, 2014, at 9:45 a.m., revealed the nurse was "providing 1:1 monitoring" of resident #28 who had sustained two falls in the last week. Observation of the nurse revealed the nurse had the resident in visual proximity but was also performing nursing tasks and care of the other residents on the unit. Interview with the Director of Nursing Services (DNS) on April 10, 2014, at 10:10 a.m., in the conference room, confirmed the facility did not have a policy for one to one (1:1) observations and did not provide one to one care. Medical record review, observation, and interview, revealed the facility did not consistently follow their policy and procedure to investigate causes and contributing factors for each fall with new interventions to prevent further falls implemented after every fall. The nursing staff sporadically documented "one on one supervision" in the nursing notes, but there was no documentation of one on one being implemented, logged, or time frames needed for one on one supervision. The DNS confirmed the facility did not have a policy or provide one on one supervision. Resident #111 was admitted to the facility July 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS (Minimum Data Set) dated June 17, 2013, revealed the resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of three out of fifteen possible points. Continued review revealed the resident had wandering behaviors, was able to walk with supervision, and was not steady during transitions and walking, but able to stabilize without staff assistance. Facility record review of the falls investigation dated August 16, 2013, at 11:05 p.m., revealed "Resident (#111) was found on the floor, sitting on buttocks in doorway to resident's room. Resident stated I fell but was unable to answer where...was going or what...trying to do...Resident was assessed, no injury found, placed in bed, and neurological checks initiated per facility policy... Causal/contributing Factors and Observations: Resident did not have non-skid socks on, was barefoot...Recommendations/Interventions taken to prevent reoccurrence: Monitor footwear and encourage resident to have footwear on when ambulating." (an inappropriate intervention for this unsteady resident with severe cognitive impairment, known to staff to have wandering and disrobing behavior.) Review of the care plan initiated July 19, 2012 and last revised March 30, 2014, revealed no interventions for wandering. Medical record review a Progress Note dated August 26, 2013, at 11:15 p.m., revealed "Resident was found on floor sitting on buttocks with legs in front...in doorway of room...Resident noted not to have shoes on and had one sock on. Resident wandering prior to fall and noted to have one shoe on and one shoe off." Facility record review of the falls investigation revealed "...Time/Date of Occurrence: August 26, 2013...Resident (#111) found on floor sitting...in doorway of room...Causal/Contributing Factors and Observations: resident has no shoes on... Recommendations/Interventions Taken to Prevent Reoccurrence: Staff to keep reminding resident to wear shoes or non-skid socks..." (an inappropriate intervention for a resident who did not have the cognition to retain the reminders). Review of the resident's care plan revealed no new interventions had been implemented after the fall on August 26, 2013. Medical record review of a Progress Note dated November 25, 2013, at 3:15 p.m., revealed "Resident in dining room eating snack...resident spilled milk and stood to ambulate unassisted...fell to floor..." Facility record review of the falls investigation dated November 25, 2013, at 4:12 p.m., revealed "Summary and Outcome of Investigative Findings: Resident (#111) has become more unsteady but d/t (due to) cognitive loss...continues to want and try to ambulate independently. May use Broda chair due to inability to stand/transfer independently." Review of the resident's care plan revealed no revision to reflect the use of a Broda chair. Interview with Licensed Practical Nurse (LPN) #3, on April 8, 2014, at 3:30 p.m., in the D hall dining room, revealed the resident would not stay in a Broda chair or any wheelchair, walked "constantly" alone. Medical record review of the quarterly MDS dated [DATE], revealed Resident #111 had short and long term memory problems and severe cognitive impairment. The resident required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, was totally dependent for bathing and balance for sit to stand, walking, transfer, was not steady. The resident had functional limitations in range of motion to both sides, upper and lower extremities, used a wheelchair for a mobility device, and had frequent incontinence of bowel and bladder. Facility record review of the falls investigation, December 25, 2013 at 11:04 a.m., and signed by the administrator January 2, 2014, revealed "...Summary of Investigative Findings: Colored Toilet Seat to help orient to toilet due to vision changes with dementia." (Inappriopriate intervention due to wandering behavior and incontinence.) Review of resident's care plan revealed no revision to reflect the colored toilet seat intervention. Medical record review of a Progress Note dated January 10, 2014, at 3:51 p.m., revealed "At approximately 3:15 p.m. resident (#111) came stating 'I just fell '..." Facility record review of the falls investigation report dated January 10, 2014, at 6:25 p.m., revealed "...afternoon activity to be offered." Review of the resident care plan revealed activity already in place and per facility policy already provided by staff daily. Medical record review of a Progress Note dated February 8, 2014, at 10:22 a.m., revealed, "Housekeeping cleaned carpet on this unit this a.m., still damp when this resident (#111) attempted to transition from carpet to room's tile floor is when fall occurred. This happened just post activity/exercises in dining hall..." Facility record review of the falls investigation report dated February 8, 2014, "...Summary and Outcome of Investigative: Housekeeping instructed to use fans when cleaning carpet. Nurses instructed to supervise residents in common areas when fans are in use." (Intervention care planned, but is for housekeeping and staff not the resident.) Medical record review of a Progress Note dated March 27, 2014, revealed "Visitor reported to CNA that a resident had fallen. CNA entered room and found resident sitting up on side of bed. Resident (#111) was naked and urine noted on floor. Resident stated 'I fell twice, got up by myself but I'm not hurt'..." Facility record review of the falls investigation, revealed "Date/Time on 03/27/2014 at 2:15 p.m., Causal/contributing Factors and Observations: resident urinated on the floor, Recommendations/Interventions to Prevent Reoccurrence: prompted, scheduled toileting," (a routine standard of care for severely demented residents). Review of the care plan revealed no new intervention/revision for the fall March 27, 2014. Resident #45 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Closed medical record review of the care plan dated June 4, 2013, revealed "...at risk for falls related to: fell in the past 30 days. History of falls...goal: I will not have any falls with target date December 20, 2013...interventions assess for pain, call light or personal items available and in easy reach or provide reacher..." (Generic interventions seen on every care plan reviewed and are standards of care for any health care setting. Observation during the survey revealed no reachers observed on the ACU). Closed medical record review of a nursing note dated October 25, 2013, at 11:22 p.m., revealed "...transfers and ambulates self. Noted to ambulate with head down and shuffle feet..." Closed medical record review of a nursing note dated November 2, 2013, at 10:30 a.m., revealed "...self ambulates slowly w/ unsteady gait noted at times..." Closed medical record review of the Quarterly Interdisciplinary Resident Review dated December 5, 2013, at 2:30 p.m., revealed a fall risk of 13 with a "score of 10 or above deems resident at risk." Closed medical record review of the Quarterly MDS dated [DATE], revealed Resident #45 could not complete the Brief Interview for Mental Status (BIMS), had short and long term memory deficits, and cognitive skills for daily decision making were severely impaired. Evaluation for functional status revealed the resident needed extensive assistance for transfer, walk in room, and locomotion on unit, and limited assistance for walk in corridor. Balance during transitions and walking revealed moving from seated to standing position, not steady but able to stabilize without staff assistance and walking, turning around, moving on and off toilet and surface-to-surface transfer was not steady, only able to stabilize with staff assistance. Review of a falls investigation revealed Resident #45 had a witnessed fall on December 6, 2013, at 8:30 a.m., in the dining room. "Resident has multiply (multiple) [MEDICAL CONDITION]'s ([MEDICAL CONDITION], blood clots) LLE (left lower extremities) & staff has been using w/c to assist resident to dining hall for all meals/activities. Was left in dining hall in...w/c to finish up w/...am meal when this writer noticed...standing, then hit...foot on another's resident's w/c fell to floor...s/t appx (approximately) 3" (inches) long noted to L elbow (steri strips applied)...assisted x 2 (times two persons) back to w/c...Recommendations/Interventions...bed/chair alarm in place as safety reminder to ask for help...Recommendations /Interventions after review. OT (Occupational Therapy) to eval. d/t to decline, now requiring w/c..." (Bed/chair alarm and wheelchair were not care planned). Closed medical record review of the physician orders revealed no order for OT evaluation. Closed medical record review of a nursing note dated December 6, 2013, at 2:16 p.m., revealed "...fall this am just after am meal. Ambulating without assistance...turned & noted this resident trip over (other) resident's w/c & fall to the floor. Closed medical record review of the care plan revealed no new interventions initiated after the fall on December 6, 2013. Review of a falls investigations revealed, on December 8, 2014, at 11:04 a.m., Resident #45 had a witnessed fall "...missed w/c...when the w/c rolled back and resident sat in floor..." Facility interventions included "...anti-brakes/rollbacks placed to w/c..." Review of the care plan revealed the care plan was not updated for anti-brakes/rollbacks. Closed medical record review of a nursing note dated December 12, 2013, at 11:55 p.m., revealed "...resident requires x 1 assist with adls (activities of daily living) & transfers...toileted q 2 hours..." Review of a falls investigation dated December 15, 2013, at 2:00 a.m., revealed Resident #45 had an unwitnessed fall. Review of the falls investigation form revealed "...CNA found resident sitting in floor between door and roomates (roommates) bed...old skin tear on elbow was bleeding slightly..." Facility interventions included "bedside mats." Facility interventions after review included "bedside mats" with a line drawn through and "...12/15/13 (December 15, 2013) 3 day B/B (bowel and bladder) tracker initiated to eval for toileting program..." Closed medical record review revealed no documentation the Bowel and Bladder tracking was completed. Closed medical record review of a nursing note dated December 15, 2013, at 3:42 a.m., revealed "...sitting in floor between roomates (roommates) bed and door...swelling and pain left hip...send to ER for eval and tx..." Closed medical record review of a nursing note dated December 15, 2013, at 6:36 a.m., revealed "...resident returned from (acute care hospital) er...at 5:30 am. Resting at this time. No new orders..." Review of the care plan revealed no new interventions were implemented after the fall on December 15, 2013. Closed medical record review of a nursing note dated December 18, 2013, at 10:27 p.m., revealed "...toileted q2hours and as needed. Up in broda chair earlier in shift had to remind to ask for assistance to ambulate x 3 (three times)...bed in low position, call light within reach..." (Review of the care plan revealed no care plan for a Broda chair). Closed medical record review of a nursing note dated December 25, 2013, at 11:55 p.m., revealed "...resident (#45) was up in chair at start of shift, resident attempted several times to ambulate without assistance. Resident was educated several times to wait for assistance when exiting chair. Difficult time redirecting resident about not transferring self or ambulation self..." (Inappropriate, resident did not have the cognitive skills to understand or retain 'education'). Review of a falls investigation dated January 4, 2014, at 1:38 a.m., revealed Resident #45 had an unwitnessed fall. Review of the facility falls investigation form revealed "...resident noted to be on floor, sitting upright by...bathroom door. Resident had an incontinent episode resident stated 'I needed to go to the bathroom.' Facility interventions included "...1. Visisted (visited) room more frequently 2. Non skid socks applied 3. Door opened to hallway 4. Turned on a night light..." Review of a falls investigation dated January 10, 2014, at 7:16 a.m., revealed Resident #45 had an unwitnessed fall. Review of the facility investigation form revealed "...resident was ambulation (ambulating) without assistance and fell in hallway in front of...room. Resident was laying on...back when discovered...immediate resident protection initiated...non skid socks put on (non skid socks were to have been implemented after the fall on January 4th), night light turned on (an intervention from the January 4

Based on review of facility policy, review of staff in-services, medical record review, review of the facility fall investigations, interview, observation, and review of Admission Packet provided to families, the facility failed to provide supervision and effective interventions to prevent falls for five residents (#28, #111, #45, #94, and #112) of fourteen residents reviewed for falls. The facility's failure resulted in multiple falls, many unwitnessed, and placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. The Immediate Jeopardy at F-323 "K" constitutes Substandard Quality of Care. The Corporate Director of Clinical Services, the Administrator and the Director of Clinical Services (DCS) were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The findings included: Review of facility policy, Falls Management Clinical Guidelines, revised 2013 revealed "...The Interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls...This evaluation may include a screening by a rehabilitation services representative...Following resident's fall...Appropriate interventions are implemented...Care plan is updated...Monitoring Compliance-The following elements are in place for the center to demonstrate satisfactory compliance with the guide...Residents at risk for falls are care planned with individualized interventions..." Review of facility policy, Fall Risk/Post Fall Assessment Process, not dated revealed, "...Following A Fall...Injury...Review, update care plan & (and) educate/communicate to staff. Complete Post Fall Investigation..." Review of facility policy, Post Fall Investigation Summary Guidelines for Completion, revised 2013 revealed, "...Evaluate for causative factors...Attempt to establish what the resident was doing/attempting to do prior to the fall. Did the resident fail to request assistance...Care Plan Developed/Revised as Indicated: Identify if the care plan was updated and new approaches to be implemented...Recommendations and Interventions Post Fall: Identify any new interventions that will be immediately implemented to reduce the potential for falls to reoccur...Recommendations implemented shall be recorded on the report and plan of care revised as necessary..." Review of a staff in-service, Reducing the Risk of Resident Falls, provided to nursing staff in January 2014 revealed, "...Evaluation of the causal factors leading to a resident fall helps support relevant and consistent interventions, which may help prevent future occurrences...Revising the resident's plan of care and/or facility practices, as needed, to reduce the likelihood of another fall...Fall Reduction Program...The Plan of Care should be reviewed and revised with interventions after each fall, as appropriate...Interdisciplinary Team (IDT) Strategies...Formulate interdisciplinary goals addressing safety. Identify specific strategies in the care plan for reducing the risk of falls...Reporting and Documentation When a resident falls, complete and document the following...Measure to prevent future falls based on the fall assessment. Care plan interventions (include the fall risk assessment score and resident and family/responsible party education). The response to interventions, progress or decline...Residents who need physical/occupational therapy evaluations will have his/her attending physician contacted for an evaluation order...The IDT will address any corrective action on the plan of care..." Medical record review and facility falls investigation review revealed quarterly fall risk assessments are completed on the residents but no documentation of a fall risk assessment score is on the falls investigation or nursing notes. Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated December 14, 2013, revealed, "...At risk for falls related to: Use of medication, History of falls, cognitive/communication deficits, assist needed wtih (with) bed mobility/transfers, incontinence, new environment/room...goal I will not have any fall related injuries..." Medical record review of the physician history and physical dated December 19, 2013, revealed, "...is a high fall risk...patient is appropriate for memory unit...fall precautions..." Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #28 had short and long term memory problem and severely impaired cognitive skills for daily decision making. Further review revealed the resident had wandering behavior "daily" and needed supervision (oversight, encouragement or cueing) to walk in room and in corridor; limited assistance (staff provide guided maneuvering) ambulating on unit; balance was not steady, but able to stabilize without staff assistance; and had impairment on both sides for range of motion. Continued review revealed the resident had a fall in the last month prior to admission and a fall in the last 2-6 months prior to admission. Medical record review of the facility fall investigations and Care Plans from December 2013 through April 2014 revealed the resident had fifteen falls between December 22, 2013, and April 5, 2014, as follows: Review of the care plan initiated December 14, 2013, revealed "...bed in low position...Call light or personal items available and in easy reach or provide reacher..." Review of a facility investigation dated December 22, 2013, at 1:00 a.m., revealed Resident #28 had an unwitnessed fall. Review of the facility falls investigation revealed "...resident was observed lying on floor beside bed on the left side facing the wall. Resident stated 'I rolled over too far.' Reddened area noted to lumbar region of back...neuro (neurological) checks (scheduled, frequent specific checking of resident to ensure no head injury occurred during unwitnessed fall) initiated...call light in reach (call light was on care plan from December 14, 2013)..." No cause or contributing factors were identified for the fall. No new interventions regarding the fall were updated on the care plan following the December 22, 2013, fall. Review of a facility fall investigation dated January 10, 2014, at 7:15 p.m., revealed resident #28 had an unwitnessed fall. Review of the facility falls investigation revealed "...resident room...resident was found on floor in front of bed lying on left side..." Interventions on the care plan updated January 10, 2014, included "mat beside bed." Review of a facility fall investigation dated January 13, 2014, at 4:30 p.m., revealed Resident #28 had a witnessed fall in the dining room. Review of the falls investigation revealed the resident was sitting in the wheelchair at the dining table, stood at the table, and fell before staff could get to the resident...The resident stated "no when asked if hurt..." Interventions updated on the care plan January 13, 2014, were "...low chair...MD (physician) to do med (medication) review..." Medical record review of a nursing note dated January 14, 2014, at 6:36 a.m., revealed, "...resident c/o (complain of) pain to back and hip while ambulating. ROM (Range of Motion) intact. Recent fall...new order received for x-ray to bilat (bilateral) hips and back..." Review of the falls investigation and follow-up recommendations for the fall on January 13, 2014, revealed, "...x-ray ordered d/t (due to) c/o pain. Revealed (L) (left) hip fx. (fracture)...MD ordered to send to ER (emergency room ) for eval (evaluation)..." Review of radiology reports dated January 14, 2014, from a mobile x-ray revealed "Pelvis with bilateral hips...displaced LEFT intertrochanteric (hip) fracture...Lumbar Spine, 2 views...Superior endplate fractures of L2 and L3 (lumbar spine) of uncertain age and etiology..." Medical record review of a nursing note dated January 14, 2014, at 12:23 p.m., revealed "...x-ray results received: left greater trochanteric fx...NP (nurse practitioner) reviewed med orders due to recent falls prior to receiving x-ray results and new med orders received..." Medical record review of a nursing note dated January 15, 2014, at 3:15 p.m., revealed, "...resident readmitted ...from (acute care hospital) after being treated for [REDACTED]. Resident was followed by ortho (orthopedic) surgeon and no surgery done d/t (due to) age..." Medical record review of the care plan revealed the intervention "low chair" initiated January 13, 2014. Continued review of the care plan revealed no revised interventions to reflect the non-surgical hip fracture and the need for fall interventions. Review of a falls investigation dated January 17, 2014, at 11:44 a.m., (four days after fracturing hip from a fall), revealed Resident #28 had an unwitnessed fall in the resident's room. Review of the facility falls investigation revealed, "...ambulating without assistance...while (the nurse was) obtaining blood sugar from resident down hallway this resident (#28) attempted to ambulate unassisted in...room...resident sitting upright on...bottom at foot of...bed holding...head stating 'my head is bleeding'...assessment noted 1/5" (inch) laceration in length and appx (approximate) .4 (four tenths inch) deep R (right) side of head, s/t (skin tear) R elbow appx (approximate) size of dime, s/t R hand superficial...decision made to send to (acute care hospital) ER for eval/tx (evaluation and treatment)..." Medical record review of the emergency room physician's orders [REDACTED]. The facility fall investigation interventions included, "...bed against wall to open up room, self-releasing belt for w/c (wheelchair), bed alarm while in bed..." Medical record review of a nursing note dated January 17, 2014, at 7:54 p.m., revealed "...self-releasing belt added w/ (with) resident continually removing and attempting to transfer self unassisted..." Medical record review of the nursing notes dated January 18, 2014, at 3:25 p.m., revealed "...self-releasing belt in use as instructed w/ resident able to removed (remove) at will...Very unsteady gait noted w/ teaching multiply (multiple) times this shift reminding resident to request assistance for staff to ambulate/transfer w/ uncertain understanding noted (resident did not have the cognitive ability to retain and understand instructions)..." Medical record review of the nursing notes dated January 19, 2014, at 2:28 p.m., revealed "...resident (#28) continues to ambulates (ambulate) unassisted while awake. Seatbelt alarm in place to w/c but resident continuously removes seatbelt and attempts to stand unassisted. Resident reminded to call for assist and not to ambulates (ambulate) alone..." Medical record review of a nursing note dated January 20, 2014, at 10:24 a.m., revealed "...continuously removes seat belt alarm and attempts to stand/ambulate unassisted..." Medical record review of a nursing note dated January 21, 2014, at 5:38 p.m., revealed "...impaired safety awareness/judgment by evidence of resident continued unsteady gait w/ frequent falls r/t (related to) gait. Is one on one at this time...attempts to self ambulate w/ very unsteady gait. Is one on one at this time...attempts to self ambulate w/ very unsteady gait noted..." Medical record review of a nursing note dated January 24, 2014, at 3:36 p.m., revealed "...continues to be one on one care...self releasing safety belt in place w/ resident able to unfasten & ambulate at will..." On January 30, 2014, reported by Certified Nurse Aide (CNA) #1, at 9:00 p.m., Resident #28 had an unwitnessed fall. Review of the facility falls investigation revealed the "resident attempted to ambulate without assistance in the didning (dining) room. Resident fell while ambulating before staff arrived. Resident shows no sign of injury. Resident is very non compliant with waiting for assistance...no injury noted...resident was placed at nurses station for one on one care...recommendations/interventions taken included...resident was moved to nurses station for one on one care, a snack and fluid was given...Increased supervision when up in w/c, UA (urinalysis) C&S (culture and sensitivity)..." Medical record review of a nursing note dated January 30, 2014, at 11:48 p.m., revealed "...resident continues on ATB (antibiotics) for UTI (Urinary Tract Infection)...is currently up at nurses station d/t trying to exit bed without assistance. Resident is one on one at this time...No c/o burning or pain upon voiding..." Review of the care plan dated January 14, 2014, revealed no new interventions put into place after the fall. Medical record review of a nursing note dated January 31, 2014, at 12:58 p.m., revealed "...attempts to self ambulate w/ very slow unsteady gait noted..." On January 31, 2014, at 8:30 p.m., Resident #28 had a witnessed fall "...was in another resident's room answering an alarm when...resident's alarm started sounding. CNA was currently in shower room with another resident...assisted the first resident back into bed and situated the resident...then ran to the...resident's room and witnessed the resident ambulating without assistance and starting to fall...was able to catch the resident's head so it did not hit the floor...lowered resident to floor and went for assistance in getting the resident off the floor..." Review of the investigation revealed no causal or contributing factors were identified interventions to prevent reoccurrence included "...medication changes made d/t increased restlessness and agitation..." Medical record review of a nursing noted dated January 31, 2014, at 2:45 p.m., revealed "...Hospice...notified...increase Ativan and Oxydodone (oxycodone, pain medication) to 0.5ml (militers) q 4 hours..." Review of the care plan dated December 14, 2014, revealed the interventions "...UA and C&S, supervision while in dining room..." were added on January 31, 2014,. Medical record review of lab reports and physician's orders [REDACTED]. The physician ordered Bactrim (antibiotic) for 14 days and the culture report on February 7, 2014, revealed "...urine culture yeast no antibiotic susceptibilities on this organism..." Antibiotic were continued. Review of a significant change in status MDS dated [DATE], revealed the BIMS (cognitive status) had not changed from the December 21, 2013, MDS review. Wandering behavior occurred 1 to 3 days and change in behavior or other symptoms was worse. Review of the functional status revealed the resident required extensive assistance with transfers and balance and ROM remained the same. Further review revealed the MDS indicated the resident had no falls with a major injury or bone fracture, and was frequently incontinent of bowel and bladder. Medical record review of a nursing notes dated February 2, 2014, at 2:05 p.m., revealed "...attempting to get up and down from bed and w/c. Resident (#28) requiring one on one care..." Review of the physician orders [REDACTED]. Medical record review of a nursing note dated February 3, 2014, at 9:58 a.m., revealed "...trying to get up and down from w/c..." Medical record review of a nursing note dated February 6, 2014, at 4:28 a.m., revealed "...resting in bed with bolsters in place. Resident also has alarm in place..." Review of the care plan dated December 14, 2014, revealed the bolsters were not added to the care plan. Medical record review of a nursing note dated February 6, 2014, at 4:28 a.m., revealed "...resident is continent and toileted q 2 hours and PRN (as needed)..." On February 10, 2014, at 6:50 p.m., Resident #28 had an unwitnessed fall "...resident found on floor next to bed, crying c/o hip pain...resident hip and bottom red and c/o pain...resident attempting to self ambulate. Bed alarm failed..." Review of the falls investigation revealed interventions included "...sent to ER, no injuries, bed alarm dc'd (discontinued), scheduled toileting..." Review of a nursing note dated February 10, 2014, at 6:50 p.m., revealed "...resident found on floor. Resident c/o sever (severe) hip pain...Resident is crying and holding left hip...ordered resident sent to ER for eval and treatment..." Medical record review of a nursing note dated February 10, 2014, at 11:00 p.m., revealed "...resident returned from ER. No new orders were sent back..." Review of the care plan dated December 14, 2014, revealed an updated intervention dated February 11, 2014, "...scheduled toileting..." Review of the physician orders [REDACTED]. Take resident every 2 hrs (hours) to toilet..." Medical record review of a nursing note dated February 12, 2014, at 1:50 p.m., revealed "...Resident (#28) continues to attempt to ambulates (ambulate) ad lib..." Medical record review of a nursing note dated February 13, 2014, at 12:20 a.m., revealed "...pressure relieving alarm to bed on and functioning...Several attempts to get OOB (out of bed) without assistance..." Medical record review of a nursing note dated February 15, 2014, at 12:52 a.m., revealed "...one on one care..." Medical record review of a nursing note dated February 17, 2014, at 12:27 a.m., revealed "...frequently getting up out of bed and out of...chair...resident does not comprehend safety issues..." On February 22, 2014, at 7:29 p.m., Resident (#28) had a witnessed fall "...fall from w/c...attempting to self transfer from w/c, self releasing belt was in place, resident had hold of the R handle of w/c, went to sit back down in...w/c. Handle of w/c on right side came loose & (and) resident slipped for (from) chair to floor. Witnessed by CNA coming up hallway..." Review of a falls investigation dated February 22, 2014, at 7:29 p.m., revealed Resident #28 had a witnessed fall "...fall from w/c...attempting to self transfer from w/c, self-releasing belt was in place, resident had hold of the R handle of w/c, went to sit back down in...w/c. Handle of w/c on right side came loose & (and) resident slipped for (from) chair to floor. Witnessed by CNA (Certified Nurse Aide) coming up hallway..." Review of the falls investigation report for the February 22nd fall revealed "...skin tear (about size of dime) noted to R thumb...assessed for injury, s/t noted...change in w/c w/ 2 arms that were in working condition..." Review of the care plan dated February 22, 2014, revealed a care plan for "...change in wheelchair r/t (related to) broken arm of resident personal w/c..." Medical record review of a nursing note dated February 22, 2014, at 10:17 p.m., revealed "...at this time attempting to get oob (out of bed) unassisted and out of w/c also..." Medical record review of a nursing note dated February 24, 2014, at 11:33 a.m., revealed "...continuously trying to stand up...1 on 1 provided by nurse..." Review of a falls investigation dated February 24, 2014, at 11:20 p.m., revealed Resident #28 had an unwitnessed fall "...was found in floor with alarm going off. No injuries noted...was found in...room beside bed on floor..." Review of the falls investigation interventions revealed "Alarm in place and toileting offered to pt (patient)." (Interventions that were already in place, not new interventions). Review of the falls investigation, care plan and physician orders [REDACTED]. Medical record review of a nursing note dated February 26, 2014, at 11:33 p.m., revealed "...attempting to get out of bed and wheelchair unassisted..." Review of a falls investigation dated February 28, 2014, at 12:10 a.m., revealed Resident #28 had an unwitnessed fall "...Resident in bed when pressure alarm sounded, staff entered into room to find resident lying on the left side of...body on...fall mat. Recommendations/Interventions after management review included "...Resident moved to a room closer to nurses (nurse's) station..." Review of a nursing note dated March 1, 2014, at 10:31 a.m., revealed "...resident moved...to be closer to NS (nurse's station)..." Medical record review of a nursing note dated March 5, 2014, at 1:06 p.m., revealed "...resident up in Broda chair (a type of wheelchair with expanded foot rests; chair can be reclined or tilted, like a recliner) for periods throughout the day..." Medical record review of a nursing note dated March 8, 2014, at 10:40 p.m., revealed "...resident attempted to get oob unassisted twice this shift..." Review of a falls investigation dated March 12, 2014, at 10:15 a.m., revealed Resident #28 had an unwitnessed fall "resident resting in Borda (Broda) chair in dining room...injury: reddened area: head...CNA found resident laying on right side infront (in front) of Broda chair flipped forward...redness noted to right side of head; neuro checks initiated...Recommendations/Interventions taken included...resident assisted to bed...Recommendation/Interventions taken after review included rest periods after meals..." Review of a nursing note dated March 12, 2014, at 10:59 a.m., revealed "...CNA found resident lying on floor in dining room...resident noted lying in floor on right side infront (in front) of broda chair which was flipped forwards...(another) resident was in dining room and stated '...flipped...chair' Video recording was played back which showed that resident sat up at the foot of...chair causing it to flip forward. Resident then fell to floor onto right side...redness noted to right side of head...neuro check initiated...pressure alarm on & functioning..." Review of the care plan updated March 12, 2014, revealed "...lay resident down for rest periods after meals..." Medical record review of a nursing note dated March 14, 2014, at 2:02 p.m., revealed "...resident requires frequent reminders that...can not walk or stand...often wants to climb out of...chair. Redirected; however resident doesn't understand..." Review of a falls investigation dated March 19, 2014, at 7:00 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on left side on bedside mat beside bed, injuries: abrasion: eye (left), skin tear: arm (left)...CNA heard bed alarm sounding and entered resident's room; resident lying on left side on bedside mat beside bed; bed was in lowest position and bolsters in place to bed...resident stated 'I want to get up'...Recommendations/Interventions include...get resident up in am (morning)...get up in am assist to DR (dining room) for AM meal..." Review of the falls investigation revealed no cause for the fall or for the abrasion to left eye and skin tear to left arm were identified. Medical record review of a nursing note dated March 19, 2014, at 1:26 p.m., revealed "...CNA found resident lying on left side on floor mat beside bed @ (at) 0700 (7:00 a.m.)...CNA heard bed alarm sounding and entered residents room. Resident found lying on left side on floor mat beside bed. Resident stated 'I want to get up'...abrasion noted above left eye; skin tear noted to left elbow...bed noted in lowest position with bolsters in place...Abrasion above left eye & skin tear cleansed with steri-strips applied. Neuro checks initiated..." Review of the care plan updated March 19, 2014, revealed "...get resident up to broda chair in am..." (Broda chair had previously been flipped forward by the resident attempting to sit up at foot of chair on February 12, 2014). Review of a nursing note dated March 21, 2014, at 8:30 p.m., revealed Resident #28 had an unwitnessed fall "RN (Registered Nurse) heard bed alarm going off and entered patient's room. Patient found lying on left side on floor mat beside bed. Patient just mumbling. States, 'I just wanted up.'...Old abrasion to left eye and left elbow with steri strips intact...Neurochecks in place..." Facility record review revealed no investigation for the March 21st fall. Medical record review of the care plan revealed no new interventions to prevent further falls were implemented after the fall on March 21, 2014. Medical record review of a nursing note dated March 27, 2014, at 8:20 p.m., revealed "...resident attempting to get oob unassisted several times..." Medical record review of a falls investigation dated April 1, 2014, at 9:45 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on right side in floor beside bed, injury: laceration: head...CNA heard bed alarm sound and entered resident's room; found resident (resident) lying on right side in floor beside bed; blood noted on bedside table...laceration noted above right eye; moderate amount of bleeding noted...sent to (acute care hospital) ER for eval..." Review of the facility interventions revealed bedside table and furniture was removed from the resident's bedside. Medical record review of a nursing note dated April 1, 2014, at 1:31 p.m., revealed the resident retuned to the facility from the ER with surgical glue applied to a laceration above the right eye. Medical record review of a nursing note dated April 1, 2014, at 3:04 p.m., revealed "...attempting to get out of Broda chair..." Medical record review of a nursing note dated April 2, 2014, at 11:25 a.m., revealed "...bruising noted to right eye...resident thrashing about in Broda chair...resident continues to attempt to get up...ativan (antianxiety) 0.5 ml (milliliter) given SL (sublingual) with relief noted. Resident resting in Broda chair with eyes closed..." Medical record review of the nursing notes dated April 3, 2014, at 11:24 p.m., revealed "...resident alert trying to climb out of recliner..." Medical record review of a nursing note dated April 4, 2014, at 1:31 a.m., revealed "...resident remains awake, one on one watch to prevent falls..." Review of a falls investigation dated April 5, 2014, at 6:50 p.m., revealed Resident #28 had an unwitnessed fall "...resident noted on floor in front of...geri chair in dining room...injuries: hematoma: head, skin tear: hand (right)...resident taken to hospital...noted lying on floor in dining room in front of...gerichair...2"x 2" s/t noted to top of R hand, 2"x1"x1/2" soft hematoma noted to middle of forehead...assisted x2 (2 person) back to chair. Neuro checks initiated per facility protocol r/t unwitnessed fall..." Review of the facility fall investigation revealed interventions included "...1. Received verbal to send to (acute care hospital) ER for eval/tx 2. Received verbal to obtain consult w/ (gero-psych hospital) for possible placement 3. Monitor s/t for any s/s (signs and symptoms) infection until area resolvese (resolves) 4. Continue neuro checks per facility protocol 5. MD (physician), RP (responsible party), and DNS (Director of Nursing Service) notified..." Interventions after review included "...hospice made medication changes, geri-psych consult ordered..." Review of a nursing note dated April 5, 2014, at 6:50 p.m., revealed "...fall from geri chair in dining hall just after pm meal intake...this writer assisted resident w/pm meal w/100% (percent) intake noted. Placed by window in dining hall to aide w/clean up of tables/dishware (interventions on care plan implemented after fall March 12, 2014, resident was to lay down after meals). Other staff down hall assisting other resident, this writer turned to get med (medication) for this resident when this writer heard noise. Upon turning, this resident noted to be on floor...Neuro checks...per facility protocol r/t unwitnessed fall...received verbal to send to (acute care hospital) ER for eval/tx r/t hematoma noted to forehead, get (geri-psych) consult on Monday 4/7/14..." Review of physician orders, nursing notes, and the care plan, revealed the only interventions implemented were increasing residents antianxiety and pain medication; no other safety measures were implemented while awaiting the geri-psych consult. Observation and interview with LPN (Licensed Practical Nurse) #2, on April 7, 2014, at 9:45 a.m., confirmed one CNA and one LPN were covering the D hall of ACU (Alzheimer's Care Unit) with a census of eleven residents. LPN #2 confirmed unit nurses were responsible for medication administration. All staff on each shift were responsible for providing activities, supervision, baths, dressing, and whatever needs each resident had. When a CNA was bathing a resident, the nurse was responsible for monitoring the common areas, answering call lights, and answering the unit telephone. Continued interview revealed the nurse was providing "1:1 monitoring" of resident #28 who had sustained two falls in the last week. Observation of the nurse revealed the nurse had the resident in visual proximity but was also performing nursing tasks and care of the other residents on the unit. Interview with the Director of Nursing Services (DNS) on April 10, 2014, at 10:10 a.m., in the conference room, confirmed the facility did not have a policy for one to one (1:1) observations and did not provide one to one care. Medical record review, observation, and interview revealed for Resident #28's fifteen falls, the facility did not consistently follow their policy and procedure to investigate causes and contributing factors for each fall with new interventions to prevent further falls implemented after every fall. The nursing staff sporadically documented "one on one supervision" in the nursing notes, but there was no documentation of one on one being implemented, logged, or time frames needed for one on one supervision. The DNS confirmed the facility did not have a policy or provide one on one supervision. Resident #111 was admitted to the facility July 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE], revealed the resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of three out of fifteen possible points. Continued review revealed the resident was able to walk with supervision and was not steady during transitions and walking but able to stabilize without staff assistance. Review of the care plan initiated July 19, 2012, revealed interventions in place at the time of the August 16th fall were "...activity programming, call light or personal items...in easy reach, and assess for pain..." Facility record review of the falls investigat

Based on review of facility policy, review of staff in-services, medical record review, review of the facility fall investigations, interview, observation, and review of Admission Packet provided to families, the facility failed to provide supervision and effective interventions to prevent falls for five residents (#28, #111, #45, #94, and #112) of fourteen residents reviewed for falls. The facility's failure resulted in multiple falls, many unwitnessed, and placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Immediate Jeopardy was effective on January 13, 2014, and was ongoing. The Immediate Jeopardy at F-323 "K" constitutes Substandard Quality of Care. The Corporate Director of Clinical Services, the Administrator and the Director of Clinical Services (DCS) were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The facility provided an acceptable Allegation of Compliance on April 29, 2014, and a revist on April 30, 2014, and May 1, 2014, revealed the corrective actions implemented on April 29, 2014, removed the Immediate Jeopardy. Noncompliance for F-323 continues at a "E" level citation. The findings included: Review of facility policy, Falls Management Clinical Guidelines, revised 2013 revealed "...The Interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls...This evaluation may include a screening by a rehabilitation services representative...Following resident's fall...Appropriate interventions are implemented...Care plan is updated...Monitoring Compliance-The following elements are in place for the center to demonstrate satisfactory compliance with the guide...Residents at risk for falls are care planned with individualized interventions..." Review of facility policy, Fall Risk/Post Fall Assessment Process, not dated revealed, "...Following A Fall...Injury...Review, update care plan & (and) educate/communicate to staff. Complete Post Fall Investigation..." Review of facility policy, Post Fall Investigation Summary Guidelines for Completion, revised 2013 revealed, "...Evaluate for causative factors...Attempt to establish what the resident was doing/attempting to do prior to the fall. Did the resident fail to request assistance...Care Plan Developed/Revised as Indicated: Identify if the care plan was updated and new approaches to be implemented...Recommendations and Interventions Post Fall: Identify any new interventions that will be immediately implemented to reduce the potential for falls to reoccur...Recommendations implemented shall be recorded on the report and plan of care revised as necessary..." Review of a staff in-service, Reducing the Risk of Resident Falls, provided to nursing staff in January 2014 revealed, "...Evaluation of the causal factors leading to a resident fall helps support relevant and consistent interventions, which may help prevent future occurrences...Revising the resident's plan of care and/or facility practices, as needed, to reduce the likelihood of another fall...Fall Reduction Program...The Plan of Care should be reviewed and revised with interventions after each fall, as appropriate...Interdisciplinary Team (IDT) Strategies...Formulate interdisciplinary goals addressing safety. Identify specific strategies in the care plan for reducing the risk of falls...Reporting and Documentation When a resident falls, complete and document the following...Measure to prevent future falls based on the fall assessment. Care plan interventions (include the fall risk assessment score and resident and family/responsible party education). The response to interventions, progress or decline...Residents who need physical/occupational therapy evaluations will have his/her attending physician contacted for an evaluation order...The IDT will address any corrective action on the plan of care..." Medical record review and facility falls investigation review revealed quarterly fall risk assessments are completed on the residents but no documentation of a fall risk assessment score is on the falls investigation or nursing notes. Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated December 14, 2013, revealed, "...At risk for falls related to: Use of medication, History of falls, cognitive/communication deficits, assist needed wtih (with) bed mobility/transfers, incontinence, new environment/room...goal I will not have any fall related injuries..." Medical record review of the physician history and physical dated December 19, 2013, revealed, "...is a high fall risk...patient is appropriate for memory unit...fall precautions..." Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #28 had short and long term memory problem and severely impaired cognitive skills for daily decision making. Further review revealed the resident had wandering behavior "daily" and needed supervision (oversight, encouragement or cueing) to walk in room and in corridor; limited assistance (staff provide guided maneuvering) ambulating on unit; balance was not steady, but able to stabilize without staff assistance; and had impairment on both sides for range of motion. Continued review revealed the resident had a fall in the last month prior to admission and a fall in the last 2-6 months prior to admission. Medical record review of the facility fall investigations and Care Plans from December 2013 through April 2014 revealed the resident had fifteen falls between December 22, 2013, and April 5, 2014, as follows: Review of the care plan initiated December 14, 2013, revealed "...bed in low position...Call light or personal items available and in easy reach or provide reacher..." Review of a facility investigation dated December 22, 2013, at 1:00 a.m., revealed Resident #28 had an unwitnessed fall. Review of the facility falls investigation revealed "...resident was observed lying on floor beside bed on the left side facing the wall. Resident stated 'I rolled over too far.' Reddened area noted to lumbar region of back...neuro (neurological) checks (scheduled, frequent specific checking of resident to ensure no head injury occurred during unwitnessed fall) initiated...call light in reach (call light was on care plan from December 14, 2013)..." No cause or contributing factors were identified for the fall. No new interventions regarding the fall were updated on the care plan following the December 22, 2013, fall. Review of a facility fall investigation dated January 10, 2014, at 7:15 p.m., revealed resident #28 had an unwitnessed fall. Review of the facility falls investigation revealed "...resident room...resident was found on floor in front of bed lying on left side..." Interventions on the care plan updated January 10, 2014, included "mat beside bed." Review of a facility fall investigation dated January 13, 2014, at 4:30 p.m., revealed Resident #28 had a witnessed fall in the dining room. Review of the falls investigation revealed the resident was sitting in the wheelchair at the dining table, stood at the table, and fell before staff could get to the resident...The resident stated "no when asked if hurt..." Interventions updated on the care plan January 13, 2014, were "...low chair...MD (physician) to do med (medication) review..." Medical record review of a nursing note dated January 14, 2014, at 6:36 a.m., revealed, "...resident c/o (complain of) pain to back and hip while ambulating. ROM (Range of Motion) intact. Recent fall...new order received for x-ray to bilat (bilateral) hips and back..." Review of the falls investigation and follow-up recommendations for the fall on January 13, 2014, revealed, "...x-ray ordered d/t (due to) c/o pain. Revealed (L) (left) hip fx. (fracture)...MD ordered to send to ER (emergency room ) for eval (evaluation)..." Review of radiology reports dated January 14, 2014, from a mobile x-ray revealed "Pelvis with bilateral hips...displaced LEFT intertrochanteric (hip) fracture...Lumbar Spine, 2 views...Superior endplate fractures of L2 and L3 (lumbar spine) of uncertain age and etiology..." Medical record review of a nursing note dated January 14, 2014, at 12:23 p.m., revealed "...x-ray results received: left greater trochanteric fx...NP (nurse practitioner) reviewed med orders due to recent falls prior to receiving x-ray results and new med orders received..." Medical record review of a nursing note dated January 15, 2014, at 3:15 p.m., revealed, "...resident readmitted ...from (acute care hospital) after being treated for [REDACTED]. Resident was followed by ortho (orthopedic) surgeon and no surgery done d/t (due to) age..." Medical record review of the care plan revealed the intervention "low chair" initiated January 13, 2014. Continued review of the care plan revealed no revised interventions to reflect the non-surgical hip fracture and the need for fall interventions. Review of a falls investigation dated January 17, 2014, at 11:44 a.m., (four days after fracturing hip from a fall), revealed Resident #28 had an unwitnessed fall in the resident's room. Review of the facility falls investigation revealed, "...ambulating without assistance...while (the nurse was) obtaining blood sugar from resident down hallway this resident (#28) attempted to ambulate unassisted in...room...resident sitting upright on...bottom at foot of...bed holding...head stating 'my head is bleeding'...assessment noted 1/5" (inch) laceration in length and appx (approximate) .4 (four tenths inch) deep R (right) side of head, s/t (skin tear) R elbow appx (approximate) size of dime, s/t R hand superficial...decision made to send to (acute care hospital) ER for eval/tx (evaluation and treatment)..." Medical record review of the emergency room physician's orders [REDACTED]. The facility fall investigation interventions included, "...bed against wall to open up room, self-releasing belt for w/c (wheelchair), bed alarm while in bed..." Medical record review of a nursing note dated January 17, 2014, at 7:54 p.m., revealed "...self-releasing belt added w/ (with) resident continually removing and attempting to transfer self unassisted..." Medical record review of the nursing notes dated January 18, 2014, at 3:25 p.m., revealed "...self-releasing belt in use as instructed w/ resident able to removed (remove) at will...Very unsteady gait noted w/ teaching multiply (multiple) times this shift reminding resident to request assistance for staff to ambulate/transfer w/ uncertain understanding noted (resident did not have the cognitive ability to retain and understand instructions)..." Medical record review of the nursing notes dated January 19, 2014, at 2:28 p.m., revealed "...resident (#28) continues to ambulates (ambulate) unassisted while awake. Seatbelt alarm in place to w/c but resident continuously removes seatbelt and attempts to stand unassisted. Resident reminded to call for assist and not to ambulates (ambulate) alone..." Medical record review of a nursing note dated January 20, 2014, at 10:24 a.m., revealed "...continuously removes seat belt alarm and attempts to stand/ambulate unassisted..." Medical record review of a nursing note dated January 21, 2014, at 5:38 p.m., revealed "...impaired safety awareness/judgment by evidence of resident continued unsteady gait w/ frequent falls r/t (related to) gait. Is one on one at this time...attempts to self ambulate w/ very unsteady gait. Is one on one at this time...attempts to self ambulate w/ very unsteady gait noted..." Medical record review of a nursing note dated January 24, 2014, at 3:36 p.m., revealed "...continues to be one on one care...self releasing safety belt in place w/ resident able to unfasten & ambulate at will..." On January 30, 2014, reported by Certified Nurse Aide (CNA) #1, at 9:00 p.m., Resident #28 had an unwitnessed fall. Review of the facility falls investigation revealed the "resident attempted to ambulate without assistance in the didning (dining) room. Resident fell while ambulating before staff arrived. Resident shows no sign of injury. Resident is very non compliant with waiting for assistance...no injury noted...resident was placed at nurses station for one on one care...recommendations/interventions taken included...resident was moved to nurses station for one on one care, a snack and fluid was given...Increased supervision when up in w/c, UA (urinalysis) C&S (culture and sensitivity)..." Medical record review of a nursing note dated January 30, 2014, at 11:48 p.m., revealed "...resident continues on ATB (antibiotics) for UTI (Urinary Tract Infection)...is currently up at nurses station d/t trying to exit bed without assistance. Resident is one on one at this time...No c/o burning or pain upon voiding..." Review of the care plan dated January 14, 2014, revealed no new interventions put into place after the fall. Medical record review of a nursing note dated January 31, 2014, at 12:58 p.m., revealed "...attempts to self ambulate w/ very slow unsteady gait noted..." On January 31, 2014, at 8:30 p.m., Resident #28 had a witnessed fall "...was in another resident's room answering an alarm when...resident's alarm started sounding. CNA was currently in shower room with another resident...assisted the first resident back into bed and situated the resident...then ran to the...resident's room and witnessed the resident ambulating without assistance and starting to fall...was able to catch the resident's head so it did not hit the floor...lowered resident to floor and went for assistance in getting the resident off the floor..." Review of the investigation revealed no causal or contributing factors were identified interventions to prevent reoccurrence included "...medication changes made d/t increased restlessness and agitation..." Medical record review of a nursing noted dated January 31, 2014, at 2:45 p.m., revealed "...Hospice...notified...increase Ativan and Oxydodone (oxycodone, pain medication) to 0.5ml (militers) q 4 hours..." Review of the care plan dated December 14, 2014, revealed the interventions "...UA and C&S, supervision while in dining room..." were added on January 31, 2014,. Medical record review of lab reports and physician's orders [REDACTED]. The physician ordered Bactrim (antibiotic) for 14 days and the culture report on February 7, 2014, revealed "...urine culture yeast no antibiotic susceptibilities on this organism..." Antibiotic were continued. Review of a significant change in status MDS dated [DATE], revealed the BIMS (cognitive status) had not changed from the December 21, 2013, MDS review. Wandering behavior occurred 1 to 3 days and change in behavior or other symptoms was worse. Review of the functional status revealed the resident required extensive assistance with transfers and balance and ROM remained the same. Further review revealed the MDS indicated the resident had no falls with a major injury or bone fracture, and was frequently incontinent of bowel and bladder. Medical record review of a nursing notes dated February 2, 2014, at 2:05 p.m., revealed "...attempting to get up and down from bed and w/c. Resident (#28) requiring one on one care..." Review of the physician orders [REDACTED]. Medical record review of a nursing note dated February 3, 2014, at 9:58 a.m., revealed "...trying to get up and down from w/c..." Medical record review of a nursing note dated February 6, 2014, at 4:28 a.m., revealed "...resting in bed with bolsters in place. Resident also has alarm in place..." Review of the care plan dated December 14, 2014, revealed the bolsters were not added to the care plan. Medical record review of a nursing note dated February 6, 2014, at 4:28 a.m., revealed "...resident is continent and toileted q 2 hours and PRN (as needed)..." On February 10, 2014, at 6:50 p.m., Resident #28 had an unwitnessed fall "...resident found on floor next to bed, crying c/o hip pain...resident hip and bottom red and c/o pain...resident attempting to self ambulate. Bed alarm failed..." Review of the falls investigation revealed interventions included "...sent to ER, no injuries, bed alarm dc'd (discontinued), scheduled toileting..." Review of a nursing note dated February 10, 2014, at 6:50 p.m., revealed "...resident found on floor. Resident c/o sever (severe) hip pain...Resident is crying and holding left hip...ordered resident sent to ER for eval and treatment..." Medical record review of a nursing note dated February 10, 2014, at 11:00 p.m., revealed "...resident returned from ER. No new orders were sent back..." Review of the care plan dated December 14, 2014, revealed an updated intervention dated February 11, 2014, "...scheduled toileting..." Review of the physician orders [REDACTED]. Take resident every 2 hrs (hours) to toilet..." Medical record review of a nursing note dated February 12, 2014, at 1:50 p.m., revealed "...Resident (#28) continues to attempt to ambulates (ambulate) ad lib..." Medical record review of a nursing note dated February 13, 2014, at 12:20 a.m., revealed "...pressure relieving alarm to bed on and functioning...Several attempts to get OOB (out of bed) without assistance..." Medical record review of a nursing note dated February 15, 2014, at 12:52 a.m., revealed "...one on one care..." Medical record review of a nursing note dated February 17, 2014, at 12:27 a.m., revealed "...frequently getting up out of bed and out of...chair...resident does not comprehend safety issues..." On February 22, 2014, at 7:29 p.m., Resident (#28) had a witnessed fall "...fall from w/c...attempting to self transfer from w/c, self releasing belt was in place, resident had hold of the R handle of w/c, went to sit back down in...w/c. Handle of w/c on right side came loose & (and) resident slipped for (from) chair to floor. Witnessed by CNA coming up hallway..." Review of a falls investigation dated February 22, 2014, at 7:29 p.m., revealed Resident #28 had a witnessed fall "...fall from w/c...attempting to self transfer from w/c, self-releasing belt was in place, resident had hold of the R handle of w/c, went to sit back down in...w/c. Handle of w/c on right side came loose & (and) resident slipped for (from) chair to floor. Witnessed by CNA (Certified Nurse Aide) coming up hallway..." Review of the falls investigation report for the February 22nd fall revealed "...skin tear (about size of dime) noted to R thumb...assessed for injury, s/t noted...change in w/c w/ 2 arms that were in working condition..." Review of the care plan dated February 22, 2014, revealed a care plan for "...change in wheelchair r/t (related to) broken arm of resident personal w/c..." Medical record review of a nursing note dated February 22, 2014, at 10:17 p.m., revealed "...at this time attempting to get oob (out of bed) unassisted and out of w/c also..." Medical record review of a nursing note dated February 24, 2014, at 11:33 a.m., revealed "...continuously trying to stand up...1 on 1 provided by nurse..." Review of a falls investigation dated February 24, 2014, at 11:20 p.m., revealed Resident #28 had an unwitnessed fall "...was found in floor with alarm going off. No injuries noted...was found in...room beside bed on floor..." Review of the falls investigation interventions revealed "Alarm in place and toileting offered to pt (patient)." (Interventions that were already in place, not new interventions). Review of the falls investigation, care plan and physician orders [REDACTED]. Medical record review of a nursing note dated February 26, 2014, at 11:33 p.m., revealed "...attempting to get out of bed and wheelchair unassisted..." Review of a falls investigation dated February 28, 2014, at 12:10 a.m., revealed Resident #28 had an unwitnessed fall "...Resident in bed when pressure alarm sounded, staff entered into room to find resident lying on the left side of...body on...fall mat. Recommendations/Interventions after management review included "...Resident moved to a room closer to nurses (nurse's) station..." Review of a nursing note dated March 1, 2014, at 10:31 a.m., revealed "...resident moved...to be closer to NS (nurse's station)..." Medical record review of a nursing note dated March 5, 2014, at 1:06 p.m., revealed "...resident up in Broda chair (a type of wheelchair with expanded foot rests; chair can be reclined or tilted, like a recliner) for periods throughout the day..." Medical record review of a nursing note dated March 8, 2014, at 10:40 p.m., revealed "...resident attempted to get oob unassisted twice this shift..." Review of a falls investigation dated March 12, 2014, at 10:15 a.m., revealed Resident #28 had an unwitnessed fall "resident resting in Borda (Broda) chair in dining room...injury: reddened area: head...CNA found resident laying on right side infront (in front) of Broda chair flipped forward...redness noted to right side of head; neuro checks initiated...Recommendations/Interventions taken included...resident assisted to bed...Recommendation/Interventions taken after review included rest periods after meals..." Review of a nursing note dated March 12, 2014, at 10:59 a.m., revealed "...CNA found resident lying on floor in dining room...resident noted lying in floor on right side infront (in front) of broda chair which was flipped forwards...(another) resident was in dining room and stated '...flipped...chair' Video recording was played back which showed that resident sat up at the foot of...chair causing it to flip forward. Resident then fell to floor onto right side...redness noted to right side of head...neuro check initiated...pressure alarm on & functioning..." Review of the care plan updated March 12, 2014, revealed "...lay resident down for rest periods after meals..." Medical record review of a nursing note dated March 14, 2014, at 2:02 p.m., revealed "...resident requires frequent reminders that...can not walk or stand...often wants to climb out of...chair. Redirected; however resident doesn't understand..." Review of a falls investigation dated March 19, 2014, at 7:00 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on left side on bedside mat beside bed, injuries: abrasion: eye (left), skin tear: arm (left)...CNA heard bed alarm sounding and entered resident's room; resident lying on left side on bedside mat beside bed; bed was in lowest position and bolsters in place to bed...resident stated 'I want to get up'...Recommendations/Interventions include...get resident up in am (morning)...get up in am assist to DR (dining room) for AM meal..." Review of the falls investigation revealed no cause for the fall or for the abrasion to left eye and skin tear to left arm were identified. Medical record review of a nursing note dated March 19, 2014, at 1:26 p.m., revealed "...CNA found resident lying on left side on floor mat beside bed @ (at) 0700 (7:00 a.m.)...CNA heard bed alarm sounding and entered residents room. Resident found lying on left side on floor mat beside bed. Resident stated 'I want to get up'...abrasion noted above left eye; skin tear noted to left elbow...bed noted in lowest position with bolsters in place...Abrasion above left eye & skin tear cleansed with steri-strips applied. Neuro checks initiated..." Review of the care plan updated March 19, 2014, revealed "...get resident up to broda chair in am..." (Broda chair had previously been flipped forward by the resident attempting to sit up at foot of chair on February 12, 2014). Review of a nursing note dated March 21, 2014, at 8:30 p.m., revealed Resident #28 had an unwitnessed fall "RN (Registered Nurse) heard bed alarm going off and entered patient's room. Patient found lying on left side on floor mat beside bed. Patient just mumbling. States, 'I just wanted up.'...Old abrasion to left eye and left elbow with steri strips intact...Neurochecks in place..." Facility record review revealed no investigation for the March 21st fall. Medical record review of the care plan revealed no new interventions to prevent further falls were implemented after the fall on March 21, 2014. Medical record review of a nursing note dated March 27, 2014, at 8:20 p.m., revealed "...resident attempting to get oob unassisted several times..." Medical record review of a falls investigation dated April 1, 2014, at 9:45 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on right side in floor beside bed, injury: laceration: head...CNA heard bed alarm sound and entered resident's room; found resident (resident) lying on right side in floor beside bed; blood noted on bedside table...laceration noted above right eye; moderate amount of bleeding noted...sent to (acute care hospital) ER for eval..." Review of the facility interventions revealed bedside table and furniture was removed from the resident's bedside. Medical record review of a nursing note dated April 1, 2014, at 1:31 p.m., revealed the resident retuned to the facility from the ER with surgical glue applied to a laceration above the right eye. Medical record review of a nursing note dated April 1, 2014, at 3:04 p.m., revealed "...attempting to get out of Broda chair..." Medical record review of a nursing note dated April 2, 2014, at 11:25 a.m., revealed "...bruising noted to right eye...resident thrashing about in Broda chair...resident continues to attempt to get up...ativan (antianxiety) 0.5 ml (milliliter) given SL (sublingual) with relief noted. Resident resting in Broda chair with eyes closed..." Medical record review of the nursing notes dated April 3, 2014, at 11:24 p.m., revealed "...resident alert trying to climb out of recliner..." Medical record review of a nursing note dated April 4, 2014, at 1:31 a.m., revealed "...resident remains awake, one on one watch to prevent falls..." Review of a falls investigation dated April 5, 2014, at 6:50 p.m., revealed Resident #28 had an unwitnessed fall "...resident noted on floor in front of...geri chair in dining room...injuries: hematoma: head, skin tear: hand (right)...resident taken to hospital...noted lying on floor in dining room in front of...gerichair...2"x 2" s/t noted to top of R hand, 2"x1"x1/2" soft hematoma noted to middle of forehead...assisted x2 (2 person) back to chair. Neuro checks initiated per facility protocol r/t unwitnessed fall..." Review of the facility fall investigation revealed interventions included "...1. Received verbal to send to (acute care hospital) ER for eval/tx 2. Received verbal to obtain consult w/ (gero-psych hospital) for possible placement 3. Monitor s/t for any s/s (signs and symptoms) infection until area resolvese (resolves) 4. Continue neuro checks per facility protocol 5. MD (physician), RP (responsible party), and DNS (Director of Nursing Service) notified..." Interventions after review included "...hospice made medication changes, geri-psych consult ordered..." Review of a nursing note dated April 5, 2014, at 6:50 p.m., revealed "...fall from geri chair in dining hall just after pm meal intake...this writer assisted resident w/pm meal w/100% (percent) intake noted. Placed by window in dining hall to aide w/clean up of tables/dishware (interventions on care plan implemented after fall March 12, 2014, resident was to lay down after meals). Other staff down hall assisting other resident, this writer turned to get med (medication) for this resident when this writer heard noise. Upon turning, this resident noted to be on floor...Neuro checks...per facility protocol r/t unwitnessed fall...received verbal to send to (acute care hospital) ER for eval/tx r/t hematoma noted to forehead, get (geri-psych) consult on Monday 4/7/14..." Review of physician orders, nursing notes, and the care plan, revealed the only interventions implemented were increasing residents antianxiety and pain medication; no other safety measures were implemented while awaiting the geri-psych consult. Observation and interview with LPN (Licensed Practical Nurse) #2, on April 7, 2014, at 9:45 a.m., confirmed one CNA and one LPN were covering the D hall of ACU (Alzheimer's Care Unit) with a census of eleven residents. LPN #2 confirmed unit nurses were responsible for medication administration. All staff on each shift were responsible for providing activities, supervision, baths, dressing, and whatever needs each resident had. When a CNA was bathing a resident, the nurse was responsible for monitoring the common areas, answering call lights, and answering the unit telephone. Continued interview revealed the nurse was providing "1:1 monitoring" of resident #28 who had sustained two falls in the last week. Observation of the nurse revealed the nurse had the resident in visual proximity but was also performing nursing tasks and care of the other residents on the unit. Interview with the Director of Nursing Services (DNS) on April 10, 2014, at 10:10 a.m., in the conference room, confirmed the facility did not have a policy for one to one (1:1) observations and did not provide one to one care. Medical record review, observation, and interview revealed for Resident #28's fifteen falls, the facility did not consistently follow their policy and procedure to investigate causes and contributing factors for each fall with new interventions to prevent further falls implemented after every fall. The nursing staff sporadically documented "one on one supervision" in the nursing notes, but there was no documentation of one on one being implemented, logged, or time frames needed for one on one supervision. The DNS confirmed the facility did not have a policy or provide one on one supervision. Resident #111 was admitted to the facility July 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE], revealed the resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of three out of fifteen possible points. Continued review revealed the resident was able to walk with supervision and was not steady during transitions and walking but able to stabilize without staff assis

Based on medical record review, review of staffing schedules and hours, review of a facility job description, review of a facility employee handbook, facility policy review, review of the facility falls investigations, observation and interview, the facility failed to provide sufficient direct care staffing (Licensed Nurses and Certified Nurse Assistants (CNAs) to ensure adequate supervision and protection from falls for five residents (#28, #111, #45, #94, #112) of fourteen residents reviewed on the Alzheimer Care Unit (ACU). The facility's failure to provide sufficient direct care staff for supervision of wandering residents with high fall risk placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective on [DATE], and is ongoing. The Corporate Director of Clinical Services, the Administrator and the Director of Clinical Services (DCS) were informed of the Immediate Jeopardy on [DATE], at 12:30 p.m., in the Administrator's Office. The facility provided a acceptable Allegation of Compliance on [DATE], and a revisit on [DATE], and [DATE], revealed the corrective actions implemented on [DATE], removed the Immediate Jeopardy. Noncompliance for F-353 continues at a "E" level citation. The findings included: Medical record review and facility record review of five residents (#28, #111, #45, #94 and #112) who had fallen while at the facility, revealed a total of forty-six falls, thirty-three of which were unwitnessed occurring from [DATE] to [DATE]. Review of the ACU, hall D and E, revealed D hall had a capacity of 18 residents; E hall had a capacity of 24 residents. Review of the facility's staffing ratios revealed the normal staffing ratio for 7 a.m. to 7 p.m. was one CNA (direct care staff) per six residents and for 7 p.m. to 7a.m., 1 CNA per nine residents. Review of the facility provided documents revealed the normal staffing pattern was one licensed nurse for each of the two Alzheimer's Units per shift. Review of the ACU census revealed: [DATE]: average (av) census 37.5 [DATE]: av census 37 [DATE]: av census 37 [DATE]: av census 38.5 February 2014: av census 37.4 [DATE]: av census 35 [DATE]-10, 2014: av census 32 Review of staffing hours for the ACU on the dates of the resident's falls from [DATE] to [DATE], punch records, and staff schedules revealed: On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on night shift; E hall had 1.5 CNAs on night shift. On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on night shift; E hall had 1.5 CNAs on night shift. On [DATE], when resident #28 had a witnessed fall, D hall had 1 CNA on night shift; E hall had 1 CNA on night shift. On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on day shift, 1 CNA on night shift; E hall had 2 CNAs on the day shift. On [DATE], when resident #28 had an unwitnessed fall, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall had one CNA on night shift. On [DATE], when Resident #111 had an unwitnessed fall, D hall had 1 CNA on day shift, 1 CNA on night shift; E hall had 1.5 CNAs on day shift, 1.25 CNAs on night shift. On [DATE], when resident #111 had an unwitnessed fall, E hall had 1 CNA on night shift. On [DATE], when resident #111 fell ambulating unassisted, D hall had 1 CNA on night shift; E hall had no CNA on night shift. On [DATE], when resident #111 had an unwitnessed fall, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall had 1.5 CNAs on night shift. On [DATE], when resident #45 was left in the ACU dining room and fell unassisted, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall had 1 CNA on night shift. On [DATE], when resident #45 fell in the ACU dining room, D hall had 1 CNA for 3.5 hours of the 12 hour night shift; E hall had 1 CNA on night shift. On [DATE], when resident #45 had an unwitnessed fall, D hall had 1 CNA for night shift; E hall had 1 CNA for 7 hours of the 12 hour night shift. On January 4, 2014, when resident #45 had an unwitnessed fall, D hall had 1 CNA for 10 hours of the 12 hour night shift; E hall had 1 CNA on night shift. On [DATE], when resident #45 had an unwitnessed fall, D hall had 1.5 CNAs for night shift; E hall had 1 CNA for 7 hours of the 12 hour night shift. On February 17, 2014, when resident #45 had an unwitnessed fall, D hall had 1 CNA on day shift, 1.5 CNAs on night shift; E hall 0.5 CNAs for night shift. On [DATE], when resident #95 tried to stand unassisted and fell , D hall had 1 CNA for 7 hours of the 12 hour night shift; E hall had 1 CNA for the night shift. On [DATE], when resident #95 had an unwitnessed fall, D hall had 1.5 CNAs on day shift, 1 CNA on night shift; E hall had 1 CNA on day shift, 1.5 CNAs on night shift. On [DATE], when resident #112 had an unwitnessed fall, D hall had 1 CNA on night shift; E hall had 1 CNA on night shift. On [DATE], when resident #112 had an unwitnessed fall, D hall had 1 CNA for 9 hours of the 12 hour night shift; E hall had 1 CNA for day shift. Review of the facility's corporate description of an "Alzheimer's Care Specialist" duties revealed: "Residents with cognitive impairment require, a more constant staff presence for the implementation of the structured daily plan for each resident in their assignment, the Care Specialist is assigned to the same group of residents each shift, be dedicated only to the ACU and not assigned to other duties in the facility except in an extreme emergency and not as a routine practice, and each resident should have permanently assigned primary caregivers (one for each shift plus a relief worker), and the relief worker is a certified dementia caregiver that floats." Observations from [DATE] to [DATE] and on [DATE], on the D and E halls in the ACU, revealed both halls were staffed with one licensed nurse and one CNA on each hall on day shift. On [DATE], census in the D hall was twelve residents on day shift, one resident, #112 discharged out with family by private vehicle to another facility closer to the family. Census on [DATE], was eleven residents. Resident #111 expired at the facility on [DATE], at 7:30 p.m., leaving ten residents on [DATE]. Census on [DATE], on D hall was ten residents. Interview with the Clinical Director of the Alzheimers Care Unit (ACU) on [DATE], at 8:40 a.m., in the conference room confirmed "more staff needed" in the ACU to monitor residents and to prevent falls. Continued interview confirmed nurses and CNAs on the ACU are trained and responsible for providing activities and the family dining experience (nurses and CNA's sit at table and eat with residents) for all three day shift meals for all residents in addition to their usual nursing care duties. Further interview confirmed "lately staffing has been one nurse and one CNA on each hall, more would be better." Observation and interview with Licensed Practical Nurse (LPN) #2 on [DATE], at 2:30 p.m., in the D hall nurse's station revealed camera monitors in the station for the common areas of the unit, but nurses could only monitor all the common areas if the nurse was sitting in the nurse's station because the common areas included not only the hallway, but included the dining room, the TV room at the end of the hall and a sitting room. Observation and interview with LPN #2, on [DATE], at 9:45 a.m., in the D hall with a sleeping resident (#28) in a Broda chair beside the nurse confirmed staff worked twelve hour shifts except on Mondays when the shifts were split. LPN #2 further confirmed one CNA and one LPN were covering the D hall of the ACU that day with a census of ten residents with severe cognitive impairment, poor safety awareness, and wandering behaviors. LPN #2 confirmed unit nurses were responsible for medication administration; all staff on shift were responsible for providing activities, and supervision of the residents; "baths, dressing, whatever the resident needs" and LPN #2 stated the staff served three meals in the ACU dining room and assisted residents with eating for all three meals. LPN #2 stated when a CNA was bathing a resident the nurse was responsible for monitoring the common areas, redirecting residents, answering call lights and the unit telephone. Continued interview confirmed LPN #2 was providing 1:1 monitoring (in addition to other assigned duties) for resident #28 who had sustained two falls in the last week. Observation in the ACU dining room on E-hall, on [DATE], at 10:00 a.m., revealed twelve residents in the dining room with no staff present. Interview with LPN #6 (float nurse) and CNA #2 on [DATE], at 10:15 a.m., in the E hallway revealed there were no cameras in E hall nurse's station and staff had no unobstructed view of all the common areas on the E hall from the nurse's station. LPN #6 and CNA #2 also confirmed one LPN and one CNA were working that day on E hall, but usually not enough staff with only one nurse and one CNA. Observation on [DATE], at 6:15 p.m., in the D hall sitting room revealed LPN #2 was singing with five residents present. Further observation revealed four residents in the TV room, sleeping in the recliners with the TV on; no supervision in the room and no one in the nursing station to watch the cameras. Interview with CNA #3, on [DATE], at 10:25 a.m., in the shower room on E hall confirmed "...not enough staff when only one CNA and one nurse scheduled." Observation and interview with LPN #3 on [DATE], at 3:55 p.m., in the D hallway revealed LPN #3 sitting at a table in the dining room with four residents (one resident had a wet spot on pants five inches in diameter) doing a drawing activity. LPN #3 confirmed one CNA was at lunch, the other CNA was toileting other residents, and a call light was flashing over one of the room doors, with no one to check the resident in the room. During the interview, LPN #6 (assigned to the E hall) came to the dining room door and announced there were two CNAs on E hall but (LPN #6) was leaving the facility to go to the hospital with a laboratory specimen needing to be tested immediately and stated the D hall nurse, LPN #3, might have to help in the E hall while the nurse was delivering the lab. The E hall nurse left the unit. Review of the facility Employee Handbook dated [DATE], revealed "...You must clock out for meal periods and clock back in when returning to work..." Interview with the Director of Nursing services (DNS) on [DATE], at 10:10 a.m., in the conference room confirmed the ACU unit staffing is calculated differently from the other units and the ACU staffing should be higher than on other units. The DNS stated "available staff scheduled is divided equally between the two ACU halls and also stated that staff does not monitor residents 1:1 anywhere in the building. Continued interview with the DNS confirmed all staff work twelve hour shifts and are required by corporate policy to clock out for a lunch break every full shift worked. The DNS further confirmed that no additional staff was ever sent to cover lunch breaks on the ACU. Interview with the Medical Director (MD), on [DATE], at 11:40 a.m., in the conference room confirmed the facility did not share staffing information with the MD. The MD stated falls had been identified as a problem in the facility "but this is not your garden variety nursing home, it's an Alzheimer's unit, we can't tie them down, we don't want to overmedicate them, and they're going to fall." Interview with CNA #2, on [DATE], at 2:30 p.m., in the E hallway, confirmed not enough staff when one CNA and one nurse is scheduled, "can't do what we need to do for the residents, we usually have eighteen and we can't do all the baths if there's only one CNA, plus one CNA and one nurse can't keep track of the residents, the only way is if one staff member is at one end of the hall and the other staff member at the other end. We really need three, one to be by the dining room and the others at each end of the hall. Sometimes if we do have two CNAs and there's a call in (staff not coming to work) on the long term care halls, they pull from us to cover it." Refer F323K Substandard Quality of Care Validation of the Credible Allegations of Compliance was accomplished on-site [DATE], and [DATE], through review of facility documents, observation, and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for all licensed and certified nursing staff, related to staff coverage of the resident units. The facility provided evidence of an acuity tool to aide with ensuring adequate staffing for each resident unit. Review of the Acuity Rating Scale implemented to ensure adequate staffing on the two Alzheimer's units revealed each resident was assessed and given a score, the average of the scores was used to determine the staffing according to the level of acuity of the unit. Continued review revealed if a resident is admitted or discharged , or has changed in function the acuity will be reassessed to ensure adequate staffing for that unit. This tool was put in place on [DATE]. Review of the actual staffing for [DATE], revealed on the 7:00 a.m., to 7:00 p.m., shift one licensed nurse and one Certified Nurse Assistant (CNA) worked on the A-wing (census of 16 residents); one licensed nurse and two CNAs worked on the B-wing (census of 24 residents); one licesensed nurse and one CNA worked on the C-wing (census of 11 residents); one CNA worked as a shower tech (technician) and one CNA worked as a restorative tech for A, B, and C-wings; one licensed nurse and one CNA worked on the D-wing (census of 11 residents); and one licensed nurse and three CNAs worked on the E-wing (census of 21 residents). Observations revealed this schedule was accurate. Review of the actual staffing for [DATE], revealed on 7:00 p.m., to 7:00 a.m., shift one licensed nurse worked the A/C wings and one licensed nurse worked on the B/C wings (they shared the C-wing duties), with one CNA working 7:00p.m., to 11:00 p.m., and two CNA's working 11:00 p.m., to 7:00 a.m., on the A/C wing and two CNAs worked on the B/C wings (sharing the duties of the C-wing); one licensed nurse and one CNA worked on the D-wing; and three licensed nurses worked on the E-wing (two Licensed Practical Nurses work as needed, and filled in as CNAs for that shift). Observations revealed this schedule was accurate. Review of the actual staffing for [DATE], for the 7:00 a.m., to 7:00 p.m., shift revealed the same as the [DATE], schedule. Observations revealed this schedule was accurate. Review of the Acuity rating scale Tool for the residents living on D and E wings (Alzheimer's units) revealed the average Acuity score for the eleven residents living on D and E wings was three, and per the Acuity Rating Scale the required staff was "...Nursing 1:20 and CNA 1:12..." Observations on [DATE], and [DATE], revealed the staffing was within the parameters. Interviews with all licensed and certified staff working the [DATE], 7:00 p.m., to 7:00 a.m., shift from 10:00 p.m. to 1:00 a.m., revealed understanding of the break schedules and the need to relieve staff for breaks. Observation on the 7:00 a.m., to 7:00 p.m., shift and the 7:00 p.m., to 7:00 a.m., shift revealed staff was relieved for breaks by appropriate staff to maintain the required staffing. Review of the [DATE], schedule revealed an agency CNA worked on the B/C wings for the 7:00 p.m., to 7:00 a.m., shift. Interview with the licensed nurse that was assigned the B/C wings on [DATE], revealed the agency CNA worked with a regularly scheduled CNA and had provided "good care" for the residents. Interview also revealed the agency CNA did not work on the D and E wings that night. Review of the agency CNA's file revealed the CNA was in-serviced with the same information as the regularly scheduled CNAs to provide appropriate care prior to working the assigned shift. The facility will remain out of compliance at a Scope and Severity level of "E" a pattern of deficient practice that constitutes no actual harm with potential of more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on medical record review, facility policy review, review of facility fall reports, observation and interview, the Administrator failed to ensure a system was in place to assess residents at risk for falls for appropriateness of interventions; ensure adequate staff were available to supervise residents; and ensure a safe environment for residents at risk for falls on the Alzheimer's Care Unit (ACU). The Administrator's failure to ensure sufficient staffing on the ACU resulted in the large number of witnessed and unwitnessed falls, on the unit. The Administrator failed to ensure the facility's fall policy was implemented, resulting in five residents experiencing forty-six falls, (thirty-three unwitnessed falls), between August 16, 2013, and April 5, 2014. This failure placed resident #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services (DNS) were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F323-K, F353-K, F490-K, F501-K, and F520-K. Substandard Quality of Care was cited under F323-K. The findings included: Medical record review and falls investigation review revealed Resident #28 had fifteen falls (eleven unwitnessed falls), four visits to the emergency room and sustained a [MEDICAL CONDITION]. Resident #111 had nine falls (seven unwitnessed falls), skin tears, hematomas, a head contusion, and an emergency room visit. Resident #45 had eight falls (five unwitnessed falls), and had multiple hematomas, bruises, skin tears and a visit to the emergency room . Resident #94 had seven falls all in January of 2014 (four unwitnessed falls), and had hematomas, lacerations, and a visit to the emergency room . Resident #112 had seven falls (six unwitnessed falls), facial lacerations, and a visit to the emergency room . Review of facility falls investigations for residents #28, #111, #45, #94, and #112, revealed the facility did not implement appropriate interventions related to causes of falls taking into consideration environmental hazards, equipment maintenance and safety, and housekeeping processess. The facility failed to ensure appropriate assistive devices implemented were individualized and safe for the resident, including Broda chairs, geri chairs, seat belts, and bolsters. Review of the facility policy for the "Dedicated Alzheimer's Care Unit, Staffing Policy" undated revealed "...Policy STATEMENT: There will be sufficient consistent and qualified staff dedicated to carry out the mission, policies, and the care plan of the dementia care service...Department Heads...All facility department heads retain accountability for assessing, planning and documenting the delivery of services on the unit, as well as clinical oversight..." Interview with the Administrator on April 8, 2014, at 2:15 p.m., in the conference room revealed the D and E units were "...Enhanced Alzheimer's Program and was started somewhere around April or May of 2013. The D unit was the more advanced Alzheimer's and the E was the more long term, but now there isn't a difference..." Continued interview regarding the staffing of the unit revealed "...it isn't a behavior unit and eighty-five percent of the time they can set eyes on the patient..." Interview with the Administrator in the conference room on April 9, 2014, at 2:30 p.m., revealed falls is something "we are looking at" in regards to the high numbers, especially in January 2014. The "clinical" staff deal with that more than I do. Interview with the Director of Nursing Services (DNS) on April 10, 2014, at 10:10 a.m., in the conference room, confirmed falls had been identified as an issue in January 2014 and "...we did an ad hoc (for falls) in January because of all the falls...did not have a resolution." The residents are "...hard to direct, they get agitated, they don't understand, you have to respect their boundaries, they don't know safety, we have to adapt to their world, most of our falls are repetitive, we don't do 1:1, we expect they will fall..." No causative issue was identified by the committee for the increased number of falls on the ACU but "day shift" was the time the majority of the falls occured. Refer to F280K, F323-K, and F353-K.

Based on medical record review, facility policy review, review of facility fall reports, observation and interview, the Administrator failed to ensure a system was in place to assess residents at risk for falls for appropriateness of interventions; ensure adequate staff were available to supervise residents; and ensure a safe environment for residents at risk for falls on the Alzheimer's Care Unit (ACU). The Administrator's failure to ensure sufficient staffing on the ACU resulted in the large number of witnessed and unwitnessed falls, on the unit. The Administrator failed to ensure the facility's fall policy was implemented, resulting in five residents experiencing forty-six falls, (thirty-three unwitnessed falls), between August 16, 2013, and April 5, 2014. This failure placed resident #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services (DNS) were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F323-K, F353-K, F490-K, F501-K, and F520-K. Substandard Quality of Care was cited under F323-K. The facility provided an acceptable Allegation of Compliance on April 29, 2014, and a revisit on April 30, 2014, and May 1, 2014, revealed the corrective actions implemented on April 29, 2014, removed the Immediate Jeopardy. Noncompliance for F-490 remains at a "E" level citation. The findings included: Medical record review and falls investigation review revealed Resident #28 had fifteen falls (eleven unwitnessed falls), four visits to the emergency room and sustained a [MEDICAL CONDITION]. Resident #111 had nine falls (seven unwitnessed falls), skin tears, hematomas, a head contusion, and an emergency room visit. Resident #45 had eight falls (five unwitnessed falls), and had multiple hematomas, bruises, skin tears and a visit to the emergency room . Resident #94 had seven falls all in January of 2014 (four unwitnessed falls), and had hematomas, lacerations, and a visit to the emergency room . Resident #112 had seven falls (six unwitnessed falls), facial lacerations, and a visit to the emergency room . Review of facility falls investigations for residents #28, #111, #45, #94, and #112, revealed the facility did not implement appropriate interventions related to causes of falls taking into consideration environmental hazards, equipment maintenance and safety, and housekeeping processess. The facility failed to ensure appropriate assistive devices implemented were individualized and safe for the resident, including Broda chairs, geri chairs, seat belts, and bolsters. Review of the facility policy for the "Dedicated Alzheimer's Care Unit, Staffing Policy" undated revealed "...Policy STATEMENT: There will be sufficient consistent and qualified staff dedicated to carry out the mission, policies, and the care plan of the dementia care service...Department Heads...All facility department heads retain accountability for assessing, planning and documenting the delivery of services on the unit, as well as clinical oversight..." Interview with the Administrator on April 8, 2014, at 2:15 p.m., in the conference room revealed the D and E units were "...Enhanced Alzheimer's Program and was started somewhere around April or May of 2013. The D unit was the more advanced Alzheimer's and the E was the more long term, but now there isn't a difference..." Continued interview regarding the staffing of the unit revealed "...it isn't a behavior unit and eighty-five percent of the time they can set eyes on the patient..." Interview with the Administrator in the conference room on April 9, 2014, at 2:30 p.m., revealed falls is something "we are looking at" in regards to the high numbers, especially in January 2014. The "clinical" staff deal with that more than I do. Interview with the Director of Nursing Services (DNS) on April 10, 2014, at 10:10 a.m., in the conference room, confirmed falls had been identified as an issue in January 2014 and "...we did an ad hoc (for falls) in January because of all the falls...did not have a resolution." The residents are "...hard to direct, they get agitated, they don't understand, you have to respect their boundaries, they don't know safety, we have to adapt to their world, most of our falls are repetitive, we don't do 1:1, we expect they will fall..." No causative issue was identified by the committee for the increased number of falls on the ACU but "day shift" was the time the majority of the falls occured. Refer to F280K, F323-K, and F353-K. Vallidation of the Credible Allegation of Compliance was accomplished on-site April 30, , and May 1, 2014, through medical record review, review of facility documents, observation, and interviews with nursing and administrative staff. The facility provided evidence of the establishment of the Performance Improvement Project (PIP) committee, and the implementation of the Acuity Rating Scale to provide adequate staffing for each unit. The facility provided evidence of in-service training for fall prvention and intervention, staffing, care plan documentation, and providing a safe environment for the residents. Interview with the Executive Director on April 30, 2014, and May 1, 2014, revealed the facility leadership group, the Director of Nursing Services, and the Medical Director, reviewed the findings of the survey and implemented follow-up audit measures to assure compliance with corrective actions with initiating a Performance Improvement Project committee. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy until it provides an acceptable plan of correction.

Based on medical record review, facility policy review, review of facility fall investigations, observation, and interview, the Medical Director failed to ensure the facility's fall policy and procedures were implemented. The Medical Director failed to ensure the facility's fall policy was implemented, resulting in five residents experiencing forty-six falls (thirty-three unwitnessed falls) from August 16, 2013, through April 5, 2014. This failure placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services (DNS), were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F-323-K, F353-K, F490-K, F501-K, and F520-K. Substandard Quality of Care was cited under F323-K. The findings included: Medical record review and falls investigation review revealed Resident #28 had fifteen falls (eleven unwitnessed falls), four visits to the emergency room and sustained a [MEDICAL CONDITION]. Resident #111 had nine falls (seven unwitnessed falls), skin tears, hematomas, a head contusion, and an emergency room visit. Resident #45 had eight falls (five unwitnessed falls), and had multiple hematomas, bruises, skin tears and a visit to the emergency room . Resident #94 had seven falls all in January of 2014 (four unwitnessed falls), and had hematomas, lacerations, and a visit to the emergency room . Resident #112 had seven falls (six unwitnessed falls), facial lacerations, and a visit to the emergency room . Interview with the Medical Director on April 10, 2014, at 11:40 a.m., in the conference room, revealed "...there is a plan of correction for falls already in place, I know they inserviced everybody and got rid of the fall alarms on the D and E units..." The Medical Director further revealed "...this isn't a garden variety nursing home, can't tie them down and don't want to dope them up...other places won't take them...every building I'm in there continues to be falls...I feel they are getting more supervision and I believe there has been more staff put in place..." Further interview with the Medical Director regarding the number of falls revealed "...I go over falls with the staff individually, the Director of Nursing (DON), PT (physical therapy), and I'm here every week for five hours a week, my Nurse Practitioner is here twice a week..." Continued interview with the Medical Director regarding staffing revealed "...you can't be immediately there...I've witnessed falls, next thing you know they are on the ground...every building has that to some extent...you expect them to fall, residents have poor vision, weak bones and are going to fall..." Refer to F323-K

Based on facility policy review, medical record review, review of facility falls investigations, observations, and interview, the facility failed to follow policy to revise care plans after every fall for appropriate interventions to prevent further falls for five physically and cognitively impaired residents (#28, #111, #45, #94, #112) of fourteen residents reviewed, who resided in the Alzheimer's Care Unit (ACU). The facility's failure to review and revise residents' care plans, develop, and implement appropriate interventions to prevent falls placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services, were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F323-K, F353-K, F490-K, F501-K, and F520-K Substandard Quality of Care was cited under F323-K. The findings included: Review of the facility policy Falls Management Clinical Guidelines, revised 2013, revealed, "...The Interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls...Following resident's fall...Appropriate interventions are implemented...Care plan is updated...Monitoring Compliance The following elements are in place for the center to demonstrate satisfactory compliance with the guide...Residents at risk for falls are care planned with individualized interventions..." Review of facility policy, Fall Risk/Post Fall Assessment Process, not dated revealed, "...Following A Fall...Injury...Review, update care plan & (and) educate/communicate to staff. Complete Post Fall Investigation..." Review of facility policy, Post Fall Investigation Summary Guidelines for Completion, revised 2013 revealed, "...Evaluate for causative factors...Attempt to establish what the resident was doing/attempting to do prior to the fall. Did the resident fail to request assistance...Care Plan Developed/Revised as Indicated: Identify if the care plan was updated and new approaches to be implemented...Recommendations and Interventions Post Fall: Identify any new interventions that will be immediately implemented to reduce the potential for falls to reoccur...Recommendations implemented shall be recorded on the report and plan of care revised as necessary..." Review of a staff in-service, Reducing the Risk of Resident Falls, provided to nursing staff in January 2014 revealed, "...Evaluation of the causal factors leading to a resident fall helps support relevant and consistent interventions, which may help prevent future occurrences...Revising the resident's plan of care and/or facility practices, as needed, to reduce the likelihood of another fall...Fall Reduction Program...The Plan of Care should be reviewed and revised with interventions after each fall, as appropriate...Interdisciplinary Team (IDT) Strategies...Formulate interdisciplinary goals addressing safety. Identify specific strategies in the care plan for reducing the risk of falls...Reporting and Documentation When a resident falls, complete and document the following...Measure to prevent future falls based on the fall assessment. Care plan interventions (include the fall risk assessment score and resident and family/responsible party education). The response to interventions, progress or decline...The IDT will address any corrective action on the plan of care..." Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated December 14, 2013, revealed, "...At risk for falls related to: Use of medication, History of falls, cognitive/communication deficits, assist needed wtih (with) bed mobility/transfers, incontinence, new environment/room...goal I will not have any fall related injuries..." Medical record review of the physician history and physical dated December 19, 2013, revealed, "...is a high fall risk...patient is appropriate for memory unit...fall precautions..." Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #28 had short term memory problem, long term memory problem, and severely impaired cognitive skills for daily decision making. Further review revealed the resident had wandering behavior "daily" and needed supervision (oversight, encouragement or cueing) to walk in room and in corridor; limited assistance (staff provide guided maneuvering) ambulating on unit; balance was not steady, but able to stabilize without staff assistance; and had impairment on both sides for range of motion. Continued review revealed the resident had a fall in the last month prior to admission and a fall in the last 2-6 months prior to admission. Review of the care plan initiated December 14, 2013, revealed "...bed in low position...Call light or personal items available and in easy reach or provide reacher..." Review of a facility investigation dated December 22, 2013, at 1:00 a.m., revealed the resident had an unwitnessed fall. Review of the facility falls investigation revealed "...resident was observed lying on floor beside bed on the left side facing the wall. Resident stated 'I rolled over too far'...call light in reach." Review of the Care Plan revealed no new interventions regarding the fall were updated on the care plan following the December 22, 2013, fall. Review of a facility fall investigation dated January 10, 2014, at 7:15 p.m., revealed the resident had an unwitnessed fall. Review of the facility falls investigation revealed "...resident room...resident was found on floor in front of bed lying on left side..." Interventions on the care plan updated January 10, 2014, included "mat beside bed." Review of a facility fall investigation dated January 13, 2014, at 4:30 p.m., revealed the Resident #28 had a witnessed fall in the dining room. Review of the falls investigation revealed the resident was sitting in the wheelchair (w/c) at the dining table, stood at the table, and fell before staff could get to the resident..." Interventions updated on the care plan January 13, 2014, were "...low chair...MD (physician) to do med (medication) review..." Medical record review of a nursing note dated January 14, 2014, at 6:36 a.m., revealed, "...resident c/o (complain of) pain to back and hip while ambulating. ROM (Range of Motion) intact. Recent fall...new order received for x-ray to bilat (bilateral) hips and back..." Review of the falls investigation and follow-up recommendations for the fall on January 13, 2014, revealed, "...x-ray ordered d/t (due to) c/o pain. Revealed (L) (left) hip fx. (fracture)...MD ordered to send to ER (emergency room ) for eval. (evaluation)..." Review of radiology reports dated January 14, 2014, from a mobile x-ray revealed "Pelvis with bilateral hips...displaced LEFT intertrochanteric (hip) fracture...Lumbar Spine, 2 views...Superior endplate fractures of L2 and L3 (lumbar spine) of uncertain age and etiology..." Medical record review of a nursing note dated January 15, 2014, at 3:15 p.m., revealed, "...resident readmitted ...from (acute care hospital) after being treated for [REDACTED]. Resident was followed by ortho (orthopedic) surgeon and no surgery done d/t age..." Medical record review of the care plan revealed the intervention "low chair" initiated January 13, 2014. (No new interventions after diagnosed with [REDACTED]. Review of a falls investigation dated January 17, 2014, at 11:44 a.m., (four days after fracturing hip from a fall), revealed Resident #28 had an unwitnessed fall in the resident's room. Review of the facility falls investigation revealed, "...ambulating without assistance...at foot of...bed holding...head stating 'my head is bleeding'...decision made to send to (acute care hospital) ER for eval/tx (evaluation and treatment)..." Medical record review of the emergency room physician's order dated January 17, 2014, at 3:15 p.m., revealed, "...accidental fall, scalp laceration, head injury...continue current plan of care...staple removal in 5-7 days...neuro (neurological) checks q2h (every two hours) x (times) 24 h for changes in mental status..." (No new interventions initiated on the care plan for staple removal or wound care.) The facility interventions included, "...bed against wall to open up room, self-releasing belt for w/c (wheelchair), bed alarm while in bed..." Medical record review of a nursing note dated January 17, 2014, at 7:54 p.m., revealed "...self-releasing belt added w/ (with) resident continually removing & (and) attempting to transfer self unassisted..." Medical record review of the nursing notes dated January 18, 2014, at 3:25 p.m., revealed "...self-releasing belt in use as instructed w/resident able to removed (remove) at will...Very unsteady gait..." Medical record review of the nursing notes dated January 19, 2014, at 2:28 p.m., revealed "...resident continues to ambulates (ambulate) unassisted while awake. Seatbelt alarm in place to w/c but resident continuously removes seatbelt and attempts to stand unassisted..." Review of a falls investigation dated February 22, 2014, at 7:29 p.m., revealed Resident #28 had a witnessed fall "...fall from w/c...attempting to self transfer from w/c..." Review of the falls investigation report for the February 22nd fall revealed "...skin tear (about size of dime) noted to R (right) thumb...assessed for injury, s/t (skin tear) noted..." Medical record review of a nursing note dated February 22, 2014, at 10:17 p.m., revealed "...at this time attempting to get oob (out of bed) unassisted and out of w/c also..." Medical record review of a nursing note dated February 24, 2014, at 11:33 a.m., revealed "...continuously trying to stand up...1 on 1 provided by nurse..." (No one on one supervision initiated on the care plan.) Review of a falls investigation dated February 24, 2014, at 11:20 p.m., revealed Resident #28 had an unwitnessed fall "...was found in floor with alarm going off...Alarm in place and toileting offered to pt (patient)." (Interventions that were already in place, not new interventions). Review of the falls investigation, care plan, and physician orders revealed no new interventions to prevent further falls were put in place after the fall on February 24, 2014. Medical record review of a nursing note dated February 26, 2014, at 11:33 p.m., revealed "...attempting to get out of bed and wheelchair unassisted..." Review of a falls investigation dated February 28, 2014, at 12:10 a.m., revealed Resident #28 had an unwitnessed fall "...Resident in bed when pressure alarm sounded..." Recommendations/Interventions after management review included "...Resident moved to a room closer to nurses (nurse's) station..." (Pressure alarm was not care planned for bed or chair.) Review of a nursing note dated March 1, 2014, at 10:31 a.m., revealed "...resident moved...to be closer to NS (nurse's station)..." Medical record review of a nursing note dated March 5, 2014, at 1:06 p.m., revealed "...resident up in Broda chair (a type of wheelchair with expanded foot rests; chair can be reclined or tilted, like a recliner) for periods throughout the day..." (Broda chair was initiated on the care plan on March 19, 2014.) Medical record review of a nursing note dated March 8, 2014, at 10:40 p.m., revealed "...resident attempted to get oob unassisted twice this shift..." Review of a falls investigation dated March 12, 2014, at 10:15 a.m., revealed Resident #28 had an unwitnessed fall in the dining room,"resident resting in Borda (Broda) chair in dining room...injury: reddened area: head...CNA (Certified Nurse Aide)found resident laying on right side infront (in front) of Broda chair flipped forward...redness noted to right side of head; neuro checks initiated...Recommendations/Interventions taken included...resident assisted to bed...Recommendation/Interventions taken after review included rest periods after meals..." Review of the care plan updated March 12, 2014, revealed "...lay resident down for rest periods after meals..." Review of a falls investigation dated March 19, 2014, at 7:00 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on left side on bedside mat beside bed, injuries: abrasion: eye (left), skin tear: arm (left)...resident stated 'I want to get up'...Recommendations/Interventions include...get resident up in am (morning)...get up in am assist to DR (dining room) for AM meal..." Review of the falls investigation revealed no cause for the fall or for the abrasion to left eye and skin tear to left arm were identified. (Getting residents up for morning meal is a standard of care not an intervention.) Review of the care plan updated March 19, 2014, revealed "...get resident up to broda chair in am..." (Broda chair had previously been flipped forward by the resident attempting to sit up at foot of chair on February 12, 2014). Review of a nursing note dated March 21, 2014, at 8:30 p.m., revealed the resident had an unwitnessed fall "I just wanted up." Facility record review revealed no investigation for the March 21st fall. Medical record review of the care plan revealed no new interventions to prevent further falls were implemented after the fall on March 21, 2014. Medical record review of a nursing note dated March 27, 2014, at 8:20 p.m., revealed "...resident attempting to get oob unassisted several times..." Medical record review of a falls investigation dated April 1, 2014, at 9:45 a.m., revealed Resident #28 had an unwitnessed fall "...resident found lying on right side in floor beside bed, injury: laceration: head...sent to (acute care hospital) ER for eval..." Review of the facility interventions revealed bedside table and furniture was removed from the resident's bedside. Medical record review of a nursing note dated April 1, 2014, at 1:31 p.m., revealed the resident retuned to the facility from the ER with surgical glue applied to a laceration above the right eye. Medical record review of a nursing note dated April 1, 2014, at 3:04 p.m., revealed "...attempting to get out of Broda chair..." Medical record review of the nursing notes dated April 3, 2014, at 11:24 p.m., revealed "...resident alert trying to climb out of recliner..." Medical record review of a nursing note dated April 4, 2014, at 1:31 a.m., revealed "...resident remains awake one on one watch to prevent falls..." (No one on one supervision initiated on the care plan.) Review of a falls investigation dated April 5, 2014, at 6:50 p.m., revealed Resident #28 had an unwitnessed fall "...resident noted on floor in front of...geri chair in dining room...injuries: hematoma: head, skin tear: hand (right)...resident taken to hospital...noted lying on floor in dining room in front of...gerichair...Review of the facility fall investigation revealed interventions included "...1. Received verbal to send to (acute care hospital) ER for eval/tx (evaluation and treatment) 2. Received verbal (order) to obtain consult w/ (gero-psych hospital) for possible placement 3. Monitor s/t for any s/s (signs or symptoms) infection until area resolvese (resolves) 4. Continue neuro checks per facility protocol 5. MD (physician), RP (responsible party), and DNS (Director of Nursing Service) notified..." Interventions after review included "...hospice made medication changes, geri-psych consult ordered..." Review of a nursing note dated April 5, 2014, at 6:50 p.m., revealed "...fall from geri chair in dining hall just after pm (evening) meal intake...this writer assisted resident w/pm meal w/100% (percent) intake noted. Placed by window in dining hall to aide w/clean up of tables/dishware. (interventions on care plan implemented after fall March 12, 2014, resident was to lay down after meals). Other staff down hall assisting other resident, this writer turned to get med (medication) for this resident when this writer heard noise. Upon turning, this resident noted to be on floor...Neuro checks...per facility protocol r/t (related to) unwitnessed fall...received verbal to send to (acute care hospital) ER for eval/tx r/t hematoma noted to forehead, get (geri-psych) consult on Monday 4/7/14..." Review of physician orders, nursing notes and the care plan revealed the only interventions implemented were increasing residents antianxiety and pain medication; no other safety measures were implemented while awaiting the geri-psych consult. Review of the resident's care plan revealed no interventions related to wandering behaviors. Observation and interview with LPN #2 on April 7, 2014, at 9:45 a.m., revealed the nurse was "providing 1:1 monitoring" of resident #28 who had sustained two falls in the last week. Observation of the nurse revealed the nurse had the resident in visual proximity but was also performing nursing tasks and care of the other residents on the unit. Interview with the Director of Nursing Services (DNS) on April 10, 2014, at 10:10 a.m., in the conference room, confirmed the facility did not have a policy for one to one (1:1) observations and did not provide one to one care. Medical record review, observation, and interview, revealed the facility did not consistently follow their policy and procedure to investigate causes and contributing factors for each fall with new interventions to prevent further falls implemented after every fall. The nursing staff sporadically documented "one on one supervision" in the nursing notes, but there was no documentation of one on one being implemented, logged, or time frames needed for one on one supervision. The DNS confirmed the facility did not have a policy or provide one on one supervision. Resident #111 was admitted to the facility July 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS (Minimum Data Set) dated June 17, 2013, revealed the resident had severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of three out of fifteen possible points. Continued review revealed the resident had wandering behaviors, was able to walk with supervision, and was not steady during transitions and walking, but able to stabilize without staff assistance. Facility record review of the falls investigation dated August 16, 2013, at 11:05 p.m., revealed "Resident (#111) was found on the floor, sitting on buttocks in doorway to resident's room. Resident stated I fell but was unable to answer where...was going or what...trying to do...Resident was assessed, no injury found, placed in bed, and neurological checks initiated per facility policy... Causal/contributing Factors and Observations: Resident did not have non-skid socks on, was barefoot...Recommendations/Interventions taken to prevent reoccurrence: Monitor footwear and encourage resident to have footwear on when ambulating." (an inappropriate intervention for this unsteady resident with severe cognitive impairment, known to staff to have wandering and disrobing behavior.) Review of the care plan initiated July 19, 2012 and last revised March 30, 2014, revealed no interventions for wandering. Medical record review a Progress Note dated August 26, 2013, at 11:15 p.m., revealed "Resident was found on floor sitting on buttocks with legs in front...in doorway of room...Resident noted not to have shoes on and had one sock on. Resident wandering prior to fall and noted to have one shoe on and one shoe off." Facility record review of the falls investigation revealed "...Time/Date of Occurrence: August 26, 2013...Resident (#111) found on floor sitting...in doorway of room...Causal/Contributing Factors and Observations: resident has no shoes on... Recommendations/Interventions Taken to Prevent Reoccurrence: Staff to keep reminding resident to wear shoes or non-skid socks..." (an inappropriate intervention for a resident who did not have the cognition to retain the reminders). Review of the resident's care plan revealed no new interventions had been implemented after the fall on August 26, 2013. Medical record review of a Progress Note dated November 25, 2013, at 3:15 p.m., revealed "Resident in dining room eating snack...resident spilled milk and stood to ambulate unassisted...fell to floor..." Facility record review of the falls investigation dated November 25, 2013, at 4:12 p.m., revealed "Summary and Outcome of Investigative Findings: Resident (#111) has become more unsteady but d/t (due to) cognitive loss...continues to want and try to ambulate independently. May use Broda chair due to inability to stand/transfer independently." Review of the resident's care plan revealed no revision to reflect the use of a Broda chair. Interview with Licensed Practical Nurse (LPN) #3, on April 8, 2014, at 3:30 p.m., in the D hall dining room, revealed the resident would not stay in a Broda chair or any wheelchair, walked "constantly" alone. Medical record review of the quarterly MDS dated [DATE], revealed Resident #111 had short and long term memory problems and severe cognitive impairment. The resident required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, was totally dependent for bathing and balance for sit to stand, walking, transfer, was not steady. The resident had functional limitations in range of motion to both sides, upper and lower extremities, used a wheelchair for a mobility device, and had frequent incontinence of bowel and bladder. Facility record review of the falls investigation, December 25, 2013 at 11:04 a.m., and signed by the administrator January 2, 2014, revealed "...Summary of Investigative Findings: Colored Toilet Seat to help orient to toilet due to vision changes with dementia." (Inappriopriate intervention due to wandering behavior and incontinence.) Review of resident's care plan revealed no revision to reflect the colored toilet seat intervention. Medical record review of a Progress Note dated January 10, 2014, at 3:51 p.m., revealed "At approximately 3:15 p.m. resident (#111) came stating 'I just fell '..." Facility record review of the falls investigation report dated January 10, 2014, at 6:25 p.m., revealed "...afternoon activity to be offered." Review of the resident care plan revealed activity already in place and per facility policy already provided by staff daily. Medical record review of a Progress Note dated February 8, 2014, at 10:22 a.m., revealed, "Housekeeping cleaned carpet on this unit this a.m., still damp when this resident (#111) attempted to transition from carpet to room's tile floor is when fall occurred. This happened just post activity/exercises in dining hall..." Facility record review of the falls investigation report dated February 8, 2014, "...Summary and Outcome of Investigative: Housekeeping instructed to use fans when cleaning carpet. Nurses instructed to supervise residents in common areas when fans are in use." (Intervention care planned, but is for housekeeping and staff not the resident.) Medical record review of a Progress Note dated March 27, 2014, revealed "Visitor reported to CNA that a resident had fallen. CNA entered room and found resident sitting up on side of bed. Resident (#111) was naked and urine noted on floor. Resident stated 'I fell twice, got up by myself but I'm not hurt'..." Facility record review of the falls investigation, revealed "Date/Time on 03/27/2014 at 2:15 p.m., Causal/contributing Factors and Observations: resident urinated on the floor, Recommendations/Interventions to Prevent Reoccurrence: prompted, scheduled toileting," (a routine standard of care for severely demented residents). Review of the care plan revealed no new intervention/revision for the fall March 27, 2014. Resident #45 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Closed medical record review of the care plan dated June 4, 2013, revealed "...at risk for falls related to: fell in the past 30 days. History of falls...goal: I will not have any falls with target date December 20, 2013...interventions assess for pain, call light or personal items available and in easy reach or provide reacher..." (Generic interventions seen on every care plan reviewed and are standards of care for any health care setting. Observation during the survey revealed no reachers observed on the ACU). Closed medical record review of a nursing note dated October 25, 2013, at 11:22 p.m., revealed "...transfers and ambulates self. Noted to ambulate with head down and shuffle feet..." Closed medical record review of a nursing note dated November 2, 2013, at 10:30 a.m., revealed "...self ambulates slowly w/ unsteady gait noted at times..." Closed medical record review of the Quarterly Interdisciplinary Resident Review dated December 5, 2013, at 2:30 p.m., revealed a fall risk of 13 with a "score of 10 or above deems resident at risk." Closed medical record review of the Quarterly MDS dated [DATE], revealed Resident #45 could not complete the Brief Interview for Mental Status (BIMS), had short and long term memory deficits, and cognitive skills for daily decision making were severely impaired. Evaluation for functional status revealed the resident needed extensive assistance for transfer, walk in room, and locomotion on unit, and limited assistance for walk in corridor. Balance during transitions and walking revealed moving from seated to standing position, not steady but able to stabilize without staff assistance and walking, turning around, moving on and off toilet and surface-to-surface transfer was not steady, only able to stabilize with staff assistance. Review of a falls investigation revealed Resident #45 had a witnessed fall on December 6, 2013, at 8:30 a.m., in the dining room. "Resident has multiply (multiple) [MEDICAL CONDITION]'s ([MEDICAL CONDITION], blood clots) LLE (left lower extremities) & staff has been using w/c to assist resident to dining hall for all meals/activities. Was left in dining hall in...w/c to finish up w/...am meal when this writer noticed...standing, then hit...foot on another's resident's w/c fell to floor...s/t appx (approximately) 3" (inches) long noted to L elbow (steri strips applied)...assisted x 2 (times two persons) back to w/c...Recommendations/Interventions...bed/chair alarm in place as safety reminder to ask for help...Recommendations /Interventions after review. OT (Occupational Therapy) to eval. d/t to decline, now requiring w/c..." (Bed/chair alarm and wheelchair were not care planned). Closed medical record review of the physician orders revealed no order for OT evaluation. Closed medical record review of a nursing note dated December 6, 2013, at 2:16 p.m., revealed "...fall this am just after am meal. Ambulating without assistance...turned & noted this resident trip over (other) resident's w/c & fall to the floor. Closed medical record review of the care plan revealed no new interventions initiated after the fall on December 6, 2013. Review of a falls investigations revealed, on December 8, 2014, at 11:04 a.m., Resident #45 had a witnessed fall "...missed w/c...when the w/c rolled back and resident sat in floor..." Facility interventions included "...anti-brakes/rollbacks placed to w/c..." Review of the care plan revealed the care plan was not updated for anti-brakes/rollbacks. Closed medical record review of a nursing note dated December 12, 2013, at 11:55 p.m., revealed "...resident requires x 1 assist with adls (activities of daily living) & transfers...toileted q 2 hours..." Review of a falls investigation dated December 15, 2013, at 2:00 a.m., revealed Resident #45 had an unwitnessed fall. Review of the falls investigation form revealed "...CNA found resident sitting in floor between door and roomates (roommates) bed...old skin tear on elbow was bleeding slightly..." Facility interventions included "bedside mats." Facility interventions after review included "bedside mats" with a line drawn through and "...12/15/13 (December 15, 2013) 3 day B/B (bowel and bladder) tracker initiated to eval for toileting program..." Closed medical record review revealed no documentation the Bowel and Bladder tracking was completed. Closed medical record review of a nursing note dated December 15, 2013, at 3:42 a.m., revealed "...sitting in floor between roomates (roommates) bed and door...swelling and pain left hip...send to ER for eval and tx..." Closed medical record review of a nursing note dated December 15, 2013, at 6:36 a.m., revealed "...resident returned from (acute care hospital) er...at 5:30 am. Resting at this time. No new orders..." Review of the care plan revealed no new interventions were implemented after the fall on December 15, 2013. Closed medical record review of a nursing note dated December 18, 2013, at 10:27 p.m., revealed "...toileted q2hours and as needed. Up in broda chair earlier in shift had to remind to ask for assistance to ambulate x 3 (three times)...bed in low position, call light within reach..." (Review of the care plan revealed no care plan for a Broda chair). Closed medical record review of a nursing note dated December 25, 2013, at 11:55 p.m., revealed "...resident (#45) was up in chair at start of shift, resident attempted several times to ambulate without assistance. Resident was educated several times to wait for assistance when exiting chair. Difficult time redirecting resident about not transferring self or ambulation self..." (Inappropriate, resident did not have the cognitive skills to understand or retain 'education'). Review of a falls investigation dated January 4, 2014, at 1:38 a.m., revealed Resident #45 had an unwitnessed fall. Review of the facility falls investigation form revealed "...resident noted to be on floor, sitting upright by...bathroom door. Resident had an incontinent episode resident stated 'I needed to go to the bathroom.' Facility interventions included "...1. Visisted (visited) room more frequently 2. Non skid socks applied 3. Door opened to hallway 4. Turned on a night light..." Review of a falls investigation dated January 10, 2014, at 7:16 a.m., revealed Resident #45 had an unwitnessed fall. Review of the facility investigation form revealed "...resident was ambulation (ambulating) without assistance and fell in hallway in front of...room. Resident was laying on...back when discovered...immediate resident protection initiated...non skid socks put on (non skid socks were to have been implemented after the fall on January 4th), night light turned on (an intervention from the January 4 fall)..." Recommendation/Interventions after review included "...Bed alarm added, to be used during night only when in bed..." (Inappriop

Based on medical record review, facility policy review, review of fall reports, observation, interview, and review of Quality Care Outcomes, the facility Quality Assurance Performance Improvement (QAPI) Committee failed to implement an effective action plan to address staff not following the facility's policy and procedures to prevent falls. The facility's QAPI Committee failed to ensure an effective system for management of falls resulting in five residents on the Alzheimer's Care Units (ACU) experiencing forty-six falls (thirty-three unwitnessed falls) within a six month time frame. This failure placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services (DNS), were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F323-K, F353-K, F490-K, F501-K, and F520-K. Substandard Quality of Care was cited under F323-K. The findings included: Review of the facility Falls Management Clinical Guidelines revised 2013 revealed "The center implements the falls prevention and intervention program including:...At risk residents are identified through a 'fall alert' communication system to care givers...The resident and/or resident's representative are porvided education regarding fall risk incorporating 'Fall Risk Brochure'...following a resident's fall...appropriate interventions are implemented...care plan is updated...QA&A committee minutes reflect data analysis using the information driven by the Quality Control Event Reporting System to identify systemic trends and patterns related to resident falls and appropriate plans of action...monitoring compliance...the following elements are in place for the center to demonstrate satisfactory compliance with the guide: Resident(s) are evaluated for fall risk. Communication system to identify the residents at risk for falls. Residents at risk for falls are care planned with individualized interventions...IDT evaluation is completed on the Change of Condition Report-Post Fall and validation of individualized intervention..." Review of the Fall Risk/Post Fall Assessment Process "tree" revealed "...following a fall...injury...review, update care plan & educate/communicate to staff, complete Post Fall Investigation, IDT reviews and determines any additional needs at start up...Falls committee reviews falls and reports trends and oversight of fall prevention system through QA & A monthly..." Review of the POS [REDACTED]. Attempt to establish what the resident was doing/attempting to do prior to the fall. Did the resident fail to request assistance...Care Plan Developed/Revised as Indicated: Identify if the care plan was updated and new approaches to be implemented..." Medical record review and falls investigation review revealed Resident #28 had fifteen falls (eleven unwitnessed falls), four visits to the emergency room and sustained a [MEDICAL CONDITION]. Resident #111 had nine falls (seven unwitnessed falls), skin tears, hematomas, a head contusion, and an emergency room visit. Resident #45 had eight falls (five unwitnessed falls), and had multiple hematomas, bruises, skin tears and a visit to the emergency room . Resident #94 had seven falls all in January of 2014 (four unwitnessed falls), and had hematomas, lacerations, and a visit to the emergency room . Resident #112 had seven falls (six unwitnessed falls), facial lacerations, and a visit to the emergency room . Interview with the Director of Quality Assurance, who was also the Director of Nursing Service (DNS), and the Administrator, on April 2, 2014, at 11:20 a.m., in the DNS's office, revealed the committee looked at falls and put plans into place when issues were identified. Continued interview revealed the committee had not identified any problems with tracking falls. Further interview confirmed falls had been identified as an issue in January 2014 and "...we did an ad hoc in January because of all the falls...did not have an 'oh this is it' resolution. The residents are hard to direct, they get agitated, they don't understand, you have to respect their boundaries, they don't know safety, we have to adapt to their world, most of our falls are repetitive, we don't do 1:1, we expect they will fall..." No causative issue was identified by the committee for the increased number of falls on the ACU but "day shift" was the time the majority of the falls occured. Review of the Quality of Care Outcomes regarding the number of falls revealed in Janaury 2014, "thirty-three/fifty falls (33 of the 50 falls in the facility) occurred on the ACU." (Sixty-six percent.) Continued review of the Quality of Care Outcomes for February, "twenty-two/twenty-six falls (22 of the 26 falls in the facility) occurred on the ACU." (Eighty-five percent.) Continued review of the March Quality of Care Outcomes "fifteen/twenty-four falls (15 of the 24 falls in the facility) occurred on the ACU." (Sixty-two percent.) Interview with ACU CNAs #2, #3, #4, #5, and #6 on April 10-11, 2014, at various times, in the ACU hallways, confirmed they were inserviced about falls in January and February but nothing had changed in practice in the way the resident's falls are handled. Interview with CNA #2, on April 11, 2014, at 2:30 p.m., in the E hallway, confirmed not enough staff when one CNA and one nurse scheduled, "we can't do what we need to do for the residents...plus one CNA and one nurse can't keep track of these residents, the only way is if one staff member is at one end of the hall and the other staff member at the other end..." Refer to F280-K, F323-K, F353-K, F490-K, and F501-K

Based on medical record review, facility policy review, review of fall reports, observation, interview, and review of Quality Care Outcomes, the facility Quality Assurance Performance Improvement (QAPI) Committee failed to implement an effective action plan to address staff not following the facility's policy and procedures to prevent falls. The facility's QAPI Committee failed to ensure an effective system for management of falls resulting in five residents on the Alzheimer's Care Units (ACU) experiencing forty-six falls (thirty-three unwitnessed falls) within a six month time frame. This failure placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services (DNS), were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F323-K, F353-K, F490-K, F501-K, and F520-K. Substandard Quality of Care was cited under F323-K. The facility provided an acceptable allegation of Compliance on April 29, 2014, and a revisit on April 30, 2014, and May 1, 2014, revealed the corrective actions implemented on April 29, 2014, removed the Immediate Jeopardy. Noncompliance for F-520 remains at a "E" level citation. The findings included: Review of the facility Falls Management Clinical Guidelines revised 2013 revealed "The center implements the falls prevention and intervention program including:...At risk residents are identified through a 'fall alert' communication system to care givers...The resident and/or resident's representative are porvided education regarding fall risk incorporating 'Fall Risk Brochure'...following a resident's fall...appropriate interventions are implemented...care plan is updated...QA&A committee minutes reflect data analysis using the information driven by the Quality Control Event Reporting System to identify systemic trends and patterns related to resident falls and appropriate plans of action...monitoring compliance...the following elements are in place for the center to demonstrate satisfactory compliance with the guide: Resident(s) are evaluated for fall risk. Communication system to identify the residents at risk for falls. Residents at risk for falls are care planned with individualized interventions...IDT evaluation is completed on the Change of Condition Report-Post Fall and validation of individualized intervention..." Review of the Fall Risk/Post Fall Assessment Process "tree" revealed "...following a fall...injury...review, update care plan & educate/communicate to staff, complete Post Fall Investigation, IDT reviews and determines any additional needs at start up...Falls committee reviews falls and reports trends and oversight of fall prevention system through QA & A monthly..." Review of the POS [REDACTED]. Attempt to establish what the resident was doing/attempting to do prior to the fall. Did the resident fail to request assistance...Care Plan Developed/Revised as Indicated: Identify if the care plan was updated and new approaches to be implemented..." Medical record review and falls investigation review revealed Resident #28 had fifteen falls (eleven unwitnessed falls), four visits to the emergency room and sustained a [MEDICAL CONDITION]. Resident #111 had nine falls (seven unwitnessed falls), skin tears, hematomas, a head contusion, and an emergency room visit. Resident #45 had eight falls (five unwitnessed falls), and had multiple hematomas, bruises, skin tears and a visit to the emergency room . Resident #94 had seven falls all in January of 2014 (four unwitnessed falls), and had hematomas, lacerations, and a visit to the emergency room . Resident #112 had seven falls (six unwitnessed falls), facial lacerations, and a visit to the emergency room . Interview with the Director of Quality Assurance, who was also the Director of Nursing Service (DNS), and the Administrator, on April 2, 2014, at 11:20 a.m., in the DNS's office, revealed the committee looked at falls and put plans into place when issues were identified. Continued interview revealed the committee had not identified any problems with tracking falls. Further interview confirmed falls had been identified as an issue in January 2014 and "...we did an ad hoc in January because of all the falls...did not have an 'oh this is it' resolution. The residents are hard to direct, they get agitated, they don't understand, you have to respect their boundaries, they don't know safety, we have to adapt to their world, most of our falls are repetitive, we don't do 1:1, we expect they will fall..." No causative issue was identified by the committee for the increased number of falls on the ACU but "day shift" was the time the majority of the falls occured. Review of the Quality of Care Outcomes regarding the number of falls revealed in Janaury 2014, "thirty-three/fifty falls (33 of the 50 falls in the facility) occurred on the ACU." (Sixty-six percent.) Continued review of the Quality of Care Outcomes for February, "twenty-two/twenty-six falls (22 of the 26 falls in the facility) occurred on the ACU." (Eighty-five percent.) Continued review of the March Quality of Care Outcomes "fifteen/twenty-four falls (15 of the 24 falls in the facility) occurred on the ACU." (Sixty-two percent.) Interview with ACU CNAs #2, #3, #4, #5, and #6 on April 10-11, 2014, at various times, in the ACU hallways, confirmed they were inserviced about falls in January and February but nothing had changed in practice in the way the resident's falls are handled. Interview with CNA #2, on April 11, 2014, at 2:30 p.m., in the E hallway, confirmed not enough staff when one CNA and one nurse scheduled, "we can't do what we need to do for the residents...plus one CNA and one nurse can't keep track of these residents, the only way is if one staff member is at one end of the hall and the other staff member at the other end..." Refer to F280-K, F323-K, F353-K, F490-K, and F501-K Vallidation of the Credible Allegation of Compliance was accomplished on-site April 30, , and May 1, 2014, through review of facility documents, and interview with nursing and administrative staff. The facility provided evidence of establishing a Performance Improvement Project (PIP) Committee which meets five days a week and reviews each resident fall to ensure appropriate fall interventions are put into place and are documented on the resident's care plan and kardex. Continued evidence revealed follow up is completed by the Committee to ensure all new interventions are implemented correctly. The facility provided evidence the PIP committee has met for five days a week since the first meeting on April 14, 2014. Review revealed falls are reviewed and interventions are put in place to prevent further falls, the interventions are documented on the resident's care plan and kardex. The facility provided evidence of in-service training with sign-in sheets for fall prevention and intervention, staffing, care plan documentation, and providing a safe environment for the residents. Review of the facility's documentation and new interventions for a resident with a fall occuring on April 30, 2014, revealed appropriate reporting, investigation, documentation, and new interventions, were completed. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy until it provides an acceptable plan of correction.

Based on medical record review, facility policy review, review of facility fall investigations, observation, and interview, the Medical Director failed to ensure the facility's fall policy and procedures were implemented. The Medical Director failed to ensure the facility's fall policy was implemented, resulting in five residents experiencing forty-six falls (thirty-three unwitnessed falls) from August 16, 2013, through April 5, 2014. This failure placed residents #28, #111, #45, #94, and #112 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death). The facility's failure to provide an effective system for falls management was likely to place any resident at risk for falls in Immediate Jeopardy. The Corporate Director of Clinical Services, the Administrator, and the Director of Nursing Services (DNS), were informed of the Immediate Jeopardy on April 11, 2014, at 12:30 p.m., in the Administrator's Office. The Immediate Jeopardy was effective on January 13, 2014, and is ongoing. Immediate Jeopardy was cited under F280-K, F-323-K, F353-K, F490-K, F501-K, and F520-K. Substandard Quality of Care was cited under F323-K. The facility provided an acceptable Allegation of Compliance on April 29, 2014, and a revisit on April 30, 2014, and May 1, 2014, revealed the corrective actions implemented on April 29, 2014, removed the Immediate Jeopardy. Noncompliance for F-501 remains at a "E" level citation. The findings included: Medical record review and falls investigation review revealed Resident #28 had fifteen falls (eleven unwitnessed falls), four visits to the emergency room and sustained a [MEDICAL CONDITION]. Resident #111 had nine falls (seven unwitnessed falls), skin tears, hematomas, a head contusion, and an emergency room visit. Resident #45 had eight falls (five unwitnessed falls), and had multiple hematomas, bruises, skin tears and a visit to the emergency room . Resident #94 had seven falls all in January of 2014 (four unwitnessed falls), and had hematomas, lacerations, and a visit to the emergency room . Resident #112 had seven falls (six unwitnessed falls), facial lacerations, and a visit to the emergency room . Interview with the Medical Director on April 10, 2014, at 11:40 a.m., in the conference room, revealed "...there is a plan of correction for falls already in place, I know they inserviced everybody and got rid of the fall alarms on the D and E units..." The Medical Director further revealed "...this isn't a garden variety nursing home, can't tie them down and don't want to dope them up...other places won't take them...every building I'm in there continues to be falls...I feel they are getting more supervision and I believe there has been more staff put in place..." Further interview with the Medical Director regarding the number of falls revealed "...I go over falls with the staff individually, the Director of Nursing (DON), PT (physical therapy), and I'm here every week for five hours a week, my Nurse Practitioner is here twice a week..." Continued interview with the Medical Director regarding staffing revealed "...you can't be immediately there...I've witnessed falls, next thing you know they are on the ground...every building has that to some extent...you expect them to fall, residents have poor vision, weak bones and are going to fall..." Refer to F323-K Vallidation of the Credible Allegation of Compliance was accomplished on-site April 30, 2014, and May 1, 2014, through review of facility documents, observation, and interview with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for fall prevention and intervention, staffing, care plan documentation, and providing a safe environment for the residents. The facility provided evidence of the Performance Improvement Program (PIP) Committee meetings and recomendations, to monitor the interventions put in place after each resident fall. Interview with the Medical Director on May 1, 2014, at 12:30 p.m., in the conference room revealed the Medical Director reviews minutes from the PIP committee meetings, and all falls since last visit. Continued interview revealed the Medical Director reviews the resident's charts and makes recomendations as needed ie: laboratory tests, medication changes, and vital sign monitoring. The Medical Director also has been involved with the designing and implementation of the Acuity Rating Scale and stated staffing is adequate at this time. Observation of residents and staff during the revisit revealed appropriate supervision of resident movements, adequate staffing to provide care, and interventions to provide safety for the residents during the 7:00 a.m., to 7:00 p.m., shift and the 7:00 p.m., to 7:00 a.m., shift. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy until it provides an acceptable plan of correction.