Every finding on record at Landmark of Lancaster Rehabilitation and Nursing C

Based on observation, interview, record review, and review of the facility's policies and the Centers for Disease Control and Prevention (CDC) related to transmission-based precautions (TBP), the facility failed to follow CDC infection-prevention guidelines for droplet precautions by not ensuring doors to resident rooms on droplet precautions remained closed. This deficient practice had the potential to place all residents, staff, and visitors at risk for transmission of infectious respiratory pathogens. 1. Multiple observations on 12/03/2025 at 9:30 AM, 10:04 AM, 10:11 AM, and 10:30 AM, revealed the door to R88's room, identified as droplet precaution rooms, was open at least half way. CDC droplet precautions signage instructions indicated the room doors must remain closed. 3. Observation on 12/03/2025 at 10:35 AM, revealed State Trained Nurse Aide (STNA) 3 entered R88's room (a droplet precautions isolation room) only wearing a surgical mask. 2. Further observation on 12/04/2025 at 1:35 PM revealed the door to Room E16 was wide open and the resident on droplet precautions for COVID-19 was seated in a wheelchair at the room's threshold, talking with staff. The resident was not wearing a mask. The findings include: Review of the CDC Guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed staff should ensure the proper selection and use of personal protective equipment (PPE) based on the isolation precautions and potential for exposure respiratory secretions and infectious materials. Review of CDC signage titled, Special Droplet/Contact Precautions, no date, revealed everyone entering the room should clean hands when entering and leaving the room, wear a mask, wear eye protection, and don (put on) a gown and gloves at the door. According to the CDC, the door to a droplet isolation room must remain closed. Review of the facility's policy titled, Clinical Protocol for SARS-CoV-2, updated 05/15/2023, revealed staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should use an approved respirator with N95 filters, gown, gloves, and eye protection. Review of the facility's policy titled, Transmission-Based Precautions [TBP], reviewed 10/24/2022, revealed TBP include droplet precautions. TBPs were initiated when a resident developed signs and symptoms of a transmissible infection or had laboratory confirmed infection and was at risk for transmitting the infection to other residents. According to the policy staff who enter the room of a resident under droplet isolation should wear a mask, gloves, gown, goggles/face shield. The policy stated further staff should remove the PPE before exiting the room and perform hand hygiene. Review of the admission Record found in R34's electronic health record (EHR) revealed the facility admitted the resident on 04/29/2025 with diagnoses to include chronic obstructive pulmonary disease (COPD), arthritis, and schizophrenia. Review of the quarterly Minimum Data Set [MDS], found in R34's EHR with an assessment reference date (ARD) of 10/22/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating the resident was severely impaired. Review of the Order Summary Report, dated 09/2025, and found in R34's EHR, revealed on 12/01/2025 the physician ordered the resident be in droplet isolation for diagnosis of COVID-19. Review of the Comprehensive Care Plan [CCP], no date, and found in R34's EHR, revealed the resident was care planned 11/29/2025 for testing positive for COVID-19 and requiring droplet isolation precautions. The Residents Care Plan directed staff to implement droplet isolation precautions each shift for 10 days. On 12/02/2025, the care plan instructed staff to encourage the resident to remain in his room. A revision dated 12/03/2025 continued to direct staff to encourage the resident to stay in the room and added the residents should be encouraged to wear masks prior to leaving the room. The 12/03/2025 revision also indicated the room door may be left open due to safety concerns. Review of the admission Record found in R86's EHR, revealed the facility admitted the resident on 09/11/2023 with diagnoses to include hemiplegia of non-dominant side, memory deficient following cerebral infarction, and immunodeficiency. Review of R86's quarterly MDS, with an ARD of 10/28/2025, revealed the resident had a BIMS score of 12 out of 15 indicating the resident was moderately impaired Review of the Order Summary Report, dated 09/2025, and found in R86's EHR, revealed on 12/01/2025 the physician ordered the resident be in droplet isolation for diagnosis of COVID-19. Review of the CCP, no date, and found in R86's EHR, revealed the resident was care planned 11/29/2025 for testing positive for COVID-19 and requiring droplet isolation precautions. The care plan directed staff to initiate droplet isolation precautions each shift for 10 days. On 12/02/2025, the care plan instructed staff to encourage the resident to remain in his room. A revision dated 12/03/2025 continued to direct staff to encourage the resident to stay in the room and added the residents should be encouraged to wear masks prior to leaving the room. The 12/03/2025 revision also indicated the room door may be left open due to safety concerns. Review of the admission Record found in R88's EHR, revealed the facility admitted the resident on 05/05/2025 with diagnoses to include Alzheimer's disease, immunodeficiency, and cognitive communication deficit. Review of R88's quarterly MDS, with an ARD of 09/28/2025, revealed a BIMS assessment was not conducted. Staff assessment for mental status revealed R88 had short and long memory problems, had no memory recall ability, and was severely impaired related to cognitive skills for decision making. Review of the Order Summary Report, dated 09/2025, and found in R88's EHR, revealed on 12/02/2025 the physician ordered the resident be in droplet isolation for diagnosis of COVID-19. Review of the CCP, no date, and found in R88's EHR, revealed the resident was care planned 12/02/2025 for testing positive for COVID-19 and requiring droplet isolation precautions. The care plan directed staff to initiate droplet isolation precautions each shift for 10 days, and to encourage resident to stay in room. A revision dated 12/03/2025 continued to direct staff to encourage the resident to stay in the room and added the residents should be encouraged to wear masks prior to leaving the room. The 12/03/2025 revision also indicated the room door may be left open due to safety concerns. During an interview with STNA3 on 12/03/2025 at 10:35 AM, she stated she had received training on standard and TBP and was aware R88 was on droplet precautions for COVID-19. When asked by the State Survey Agency (SSA) about the facilities policy for donning PPE prior to entering an isolation room, SRNA3 stated she entered the room just to peek in and did not don PPE because she did not provide care. When asked by the SSA what the CDC signs required, we reviewed the signage, and the signage directed staff to don a gown, gloves, mask and eye protection. During an interview on 12/03/2025 at 1:50 PM with LPN8, she stated she was aware R34, R86, and R88 were on droplet precautions for COVID-19. When asked by the SSA about the requirements for droplet precautions, she stated staff must follow the instructions posted on the TBP signs outside of the isolation room. LPN8 stated staff were required to wear an N95 respirator, face shield or goggles, gown, and gloves while in a droplet precaution room. When asked if the resident's door should remain closed while on droplet precautions, LPN8 stated according to CDC guidelines and TBP signage, the door should be kept closed. During an interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 12/03/2025 at 11:35 AM, she stated all employees received infection prevention and control (IPCP) education and training, including hand hygiene, personal protective equipment, and transmission-based precautions. The ADON/IP stated staff complete a post-education test to assess understanding and participate in an annual skills workshop to ensure competencies were maintained. When informed by the SSA the doors to R86 and R88 rooms (both on droplet precautions) were observed open, and that R86 was seated at the threshold without a mask, the ADON/IP stated this was not consistent with facility expectations. A continued interview with the ADON/IP on 12/04/2025 at 11:37 AM, revealed R86 did not like the door closed and frequently came to the doorway to look out. The ADON/IP stated R86 had been educated regarding his COVID-19 diagnosis and instructed to wear a mask when within six feet of the doorway; however, she stated R86 was sometimes noncompliant and would refuse to wear a mask, though staff were expected to redirect him. The ADON/IP stated she was unsure why, at the time of the observation, R86's door was open, and the resident was unmasked at the threshold without staff intervention. The ADON/IP stated this practice was not in accordance with facility policy. Furthermore, the ADON/IP stated staff should know and follow IPCP one hundred percent of the time, including awareness of the resident's condition and adherence to posted CDC signage. The ADON/IP stated it was her expectation that staff follow the facility's infection prevention and control policies and procedures. The ADON/IP stated these practices were necessary to protect the safety and welfare of residents, staff, and visitors. During an interview with the Director of Nursing (DON) on 12/04/2025 at 11:14 AM, she stated the required PPE before entering the room for residents with COVID-19 included a gown, gloves, and an N95 respirator. The DON stated all staff were fit tested upon hire and were expected to change their mask upon exiting a resident's room. The DON stated staff receive education on caring for residents with COVID-19. When asked why the doors to the droplet precaution rooms were observed open, the DON stated R88 and R86 were identified as fall risks and stated safety was the priority. The DON stated, safety trump's everything. The DON stated staff try to keep doors closed for residents on precautions but may leave the door cracked if a resident requests it. However, the DON stated staff continue to reinforce facility infection control policy and expectations. When asked about the safety of other residents, staff and visitors related to potential exposures to infection and disease, the DON stated the facility fights the battle the best we can. The DON stated when residents were noncompliant with masking or staying in their rooms, the staff attempt to keep the resident at least six feet away from other residents and reinforce infection control practices. The DON further stated that if the door was to remain open, the resident should be care planned accordingly. The DON stated it was her expectation that all staff follow the infection prevention and control policy and procedures for the safety of residents and staff and to prevent the spread of infectious diseases. During an interview with the Administrator on 12/04/2025 at 11:25 AM, she stated it was her expectation staff adhere to facility policy related to infection control. The Administrator stated the facility followed the recommendation of the Local Health Department (LHD) and the CDC for PPE use and isolation precautions. The Administrator stated it was important to ensure the safety and health of the residents.

Based on observation, interview, record review, and facility policy, the facility failed to store drugs and biologicals in the proper storage conditions given by product instructions for 1 of 1 sampled resident, Resident (R )10. The findings include:Review of facility's policy titled Medication Storage no date given, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner, and nursing staff shall be responsible for maintaining medication storage. Added review revealed the facility shall not use deteriorated drugs or biologicals and discontinued medications shall not be used and returned to pharmacy. Further review revealed medications requiring refrigeration must be stored in a refrigerator in the drug room. On 10/01/2025 at 1:32 PM medication refrigerator for Hall HSC was observed to have a box of Formoterol Fumarate Inhalation Solution, (bronchodilator used to treat COPD), 20 MCG per 2 milliliters (ml) vials (nebulizers) stored in freezer of medication refrigerator. Added observation revealed the box was labeled with R10's name and a sticker was observed on the box saying, Do Not Freeze. Further observation revealed when the box was opened there was a buildup of frost and ice on the inside of the box and lid; and on the vials. Additional observation revealed the label indicated the supply was one hundred twenty (120) vials in box before opening. A count was performed by Licensed Practical Nurse (LPN)6 and the State Survey Agent (SSA), and fifty- eight (58) vials remained in box. There was no thermometer observed in the medication refrigerator/freezer. Review of R10's admission Record revealed the facility admitted R10 on 07/08/2025 and he passed away on 10/20/2025. Review of R 10's diagnoses included chronic obstructive pulmonary disease (COPD) (lung diseases causing breathing difficulties from restricted air flow), diabetes, and chronic respiratory failure with hypoxia (low oxygen). Review of R10's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/06/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating intact cognition. However, the resident was no longer at the facility and was not interviewed.Review of R10's order set revealed a physicians' order placed on 06/18/2025 for Formoterol Fumarate Inhalation Nebulizer Solution twenty (20) MCG per 2 ml, inhale orally via nebulizer two times a day for COPD. Further review revealed the nebulizers were discontinued on 07/04/2025. Review of R10's Comprehensive Care Plan (CCP) revealed a focus which included R10 being a risk for respiratory infection related to COPD, shortness of air, and decreased oxygen saturation. Added review of R10's CCP revealed interventions placed on 12/29/2023 to include to administer nebulizer treatments per Medical Doctor (MD) order. During an interview with the facility Pharmacist on 12/04/2025 at 11:05AM, she stated the nebulizers should be store in the refrigerator and not in freezer. The Pharmacist stated the reason they should not be stored in the freezer was that the solution will freeze. When asked why that would be a concern, the Pharmacist stated the efficacy was affected once the solution thawed and the medication was not effective. During an interview with LPN6 during the observation of the medication refrigerator on 10/01/2025 at 1:32PM, LPN6 stated she did not know why the nebulizers were in the freezer since they had a label saying, Do Not Freeze and LPN6 was not sure how long they had been in the freezer. When asked why they shouldn't be in the freezer LPN6 stated, they may not work if frozen. During an interview with the Director of Nursing (DON) on 12/04/2025 at 11:30AM the DON stated her expectations of staff was to store medications per manufactures instructions. The DON stated staff should be following the facility policy and procedure for storing medications. When asked what concern she had regarding the nebulizers being stored in the freezer, the DON stated the medicine may not work. The DON stated she thought the nebulizers had been discontinued and if so, they should have been disposed of or returned properly to the pharmacy.During an interview on 12/04/2025 at 10:20 AM the Administrator stated her expectations of staff when it came to medication storage was staff were to follow policy/procedures and manufacturer's instructions for the storage of medications. The Administrator stated her concern was that if medications were not stored per manufacturers' instructions, the medications may not work. The Administrator stated she thought the freezer may be used to store items that needed to be thrown away.

Based on observation, interview, and review of facility policy, the facility failed to ensure residents receive food and drink at a safe and appetizing temperature. Observation on 07/09/2024 at 12:50 PM, of the lunch test tray, revealed the following temperatures: milk 55.5 degrees Fahrenheit (F), juice 57 degrees F, and pureed pork tenderloin 110-degrees F. Point of service temperature for the pureed pork tenderloin was not hot enough; and point of service temperatures for the milk and juice were not cold enough, resulting in these temperatures being in the danger zone. The findings include: Review of facility's policy titled Food Storage, dated 08/12/2023, revealed all food stock and prepared food products are to be stored at safe temperatures ranges at all times. However, the policy did not address what point of service temperatures should be. A policy related to food temperatures at point of service was not submitted for review. Review of https://www.fda.gov/food/buy-store-serve-safe, content current as of 03/05/2024, revealed per the Food and Drug Administration (FDA), keep hot foods at 140 F or warmer, and cold foods at 40 F or colder. The Danger zone is 40-140 degrees F. Review of Resident Counsel Minutes, dated February 2024, revealed concerns with food not cooked properly. Review of Resident Counsel Minutes, dated March 2024, revealed concerns of cold food, soggy bread, and tough hamburger. Review of Resident Counsel Minutes, dated April 2024, revealed concerns of cold burgers and hard bread. During interview, on 07/09/2024 at 9:27 AM, with Resident (R) 37, he stated the eggs were not hot, and he would like another piece of toast. The resident was sitting up in bed eating breakfast which consisted of cereal, eggs, coffee, juice, milk, and chopped/minced bacon in a bowl. During the Group Interview, conducted by the State Agency Representative, on 07/10/2024 at 2:00 PM, interviews with residents revealed food such as hamburgers were served too cold to taste good. Further interview revealed portion sizes were too small, and milk and juices were not cold. Observation on 07/09/2024 at 12:50 PM, of the last meal tray on the last food cart (test tray), which was removed from an insulated meal cart, revealed temperatures as follows: milk 55.5 degrees Fahrenheit (F), juice 57 degrees F, pureed pork tenderloin 110 degrees F, pork tenderloin slices 135 degrees F, chopped meat 140 degrees F, mashed potatoes 145 degrees F and sweet potato 172.9 degrees F. Therefore, the point of service temperature for the pureed pork tenderloin was not hot enough; and the point of service temperatures for the milk and juice were not cold enough, resulting in these temperatures being in the danger zone. During an interview with the Dietary Manager (DM), on 07/09/2024 at 5:50 PM, he stated there had been a shortage of milk cartons, and he would need to keep the milk on ice in order for it to maintain the appropriate temperature after being placed on the cart. In continued interview, he stated he would have to check the temperatures of the meat more often to ensure it stayed above the recommended temperatures. The DM further stated when hot food temperatures dropped to dangerous levels or if cold food/drink temperatures were not held at a cold enough temperature, it could cause food borne illnesses to residents. During further interview, he stated it was his responsibility to keep the food temperatures within normal limits and out of the danger zone. Per interview, he had only been in this position for a month, and was working on properly training dietary staff. During an interview, on 07/10/2024 at 9:18 PM, with Cook1, she stated the steam table kept the temperatures about 189 degrees F, which was the desired temp. Cook1 stated she would check the well water temperature before she put the food into the steamer to make sure it was at least 182 degrees or more; then she would check the food temperatures right before she plated the food for the first cart only and write the food temperatures down on the production sheet/log. Cook1 stated the steam table would keep food hot for an hour and half, and then the meat temperatures would decrease. She further stated when the temperatures dropped below safe levels, she could not serve the food, because residents could get sick. During interview, with the Regional Dietary Manager (RDM), on 07/12/2024 at 3:45 PM, she stated she had recently started in her position, and had not yet been to the facility. She further stated the Dietary Manager received the new education/training packets for the dietary staff and was responsible for providing that education. Per interview, the requirements for training included three (3) days of onsite training for the cooks, and two (2) days of onsite training for the Dietary Aides (DA). The RDM stated she was not sure if the Dietary Manager had started the training, as he was fairly new to the position. Attempts to contact the Dietician by phone, on 07/10/2024 at 8:09 PM, and 07/11/2024 at 4:53 PM, were unsuccessful. Interview with the Administrator, on 07/09/2024 at 6:00 PM, revealed the facility Dietician was out of the country at this time. During further interview with the Administrator, on 07/09/2024 at 6:00 PM, she stated it was her expectation appetizing and palatable food and drink was served to residents to encourage them to increase the amount they ate and drank. Improved nutrition and hydration status could help prevent, or aid in the recovery from illness or injury. She further stated it was her expectation all meals be served within optimal temperature ranges. The Administrator stated, failure to maintain temperatures at optimal temperatures could result in residents becoming ill.

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Observation during the initial kitchen tour, on [DATE] starting at 8:25 AM, revealed the reach in refrigerator contained a bottle of chocolate syrup, a container of cottage cheese, a one (1) pound bag of shredded cheddar cheese, two (2) 32 ounce containers of dairy drink, two (2) gallons of whole milk, one (1) box of cake mix, and a two (2) pound bag of powdered sugar which were all opened and were not labeled with the date opened. Also, there was a one (1) gallon jug of thousand island dressing and a quart of sour cream which were both opened and were not labeled with the date opened and both items were expired according to the manufacturer's expiration date. Additionally, observation during the initial kitchen tour, on [DATE], revealed the walk-in refrigerator, contained a cart with eight (8) trays containing cups of pre-poured portions of juice, tea, and milk without secure covers; lids were either off or floating in the beverage. Also the walk-in refrigerator contained two (2) opened gallon jugs of milk with no opened date; and a tray with two (2) fruit cups and three (3) cups of applesauce which were opened and uncovered. Also, observation during the initial kitchen tour, on [DATE], of the walk in freezer, revealed an opened blue plastic bag containing mixed frozen vegetables, with no opened date. Further observation during the initial kitchen tour, on [DATE], revealed the filter on the juice dispenser was covered with gray matter. Moreover, observation on [DATE] at 11:55 AM, during the lunch tray line, revealed the same cups of pre-poured portions of juice, tea and milk cups that were in the walk in refrigerator earlier during initial tour, without secure covers, were being placed on resident trays. The loose and missing lids were placed on the cups as the drinks were placed on the residents' trays. Furthermore, observation on [DATE] at 4:50 PM, revealed Cook1 left the steam table, going to the clean dish area with gloves on to obtain clean dishes; and then returned to the steam table without performing hand hygiene and donning new gloves. Additionally, observation on [DATE] at 4:50 PM, revealed Dietary Aide6, who had a beard, was observed plating beans in bowls during tray line without wearing a beard guard or hair net. In addition, observation on [DATE] at 5:15 PM, revealed Dietary Aide1 placed drinks and utensils on the meal trays during tray line without wearing gloves; and was observed pulling at or touching mask and/or face. The findings include: 1. Record review of the facility document titled, Dietary Manager Responsibility, undated, revealed it was the Dietary Manager's (DM) responsibility to ensure all food was stored properly, covered, labeled, dated, and outdated food removed. Review of the facility's policy titled, Labeling and Dating Foods, reviewed [DATE], revealed the purpose of the policy was to decrease the risk of food borne illness. Foods are labeled with the date received, the date opened and the date by which the item should be discarded. Once opened these items are refrigerated and labeled with the date opened and with discard or use by date. Bulk condiments with a Best if Used By date such as catsup, mustard and salad dressings are shelf stable for longer periods as indicated by Best if Used By date. Observation during the initial kitchen tour, on [DATE] starting at 8:25 AM, revealed the following: Observation of the reach in refrigerator revealed a bottle of chocolate syrup, a container of cottage cheese, a one (1) pound bag of shredded cheddar cheese, two (2) 32 ounce containers of dairy drink, two (2) gallons of whole milk, one (1) box of cake mix, and a two (2) pound bag of powdered sugar, which were all opened and were not labeled with the date opened or date by which the item should be discarded. Additionally, a one (1) gallon jug of thousand island dressing and a quart of sour cream were both opened and were not labeled with the date opened or date by which the item should be discarded; and both items were expired according to the manufacturer's expiration date. Observation of the walk-in refrigerator, revealed a cart with eight (8) trays containing cups of pre-poured portions of juice, tea, and milk without secure covers; lids were either off or floating in the beverage. Several cups in the trays were standing in the liquid. Also noted in the walk-in refrigerator were two (2) opened gallon jugs of milk with no opened date or date by which the item should be discarded. Additionally, there was a tray with two (2) fruit cups and three (3) cups of applesauce which were opened and uncovered. Observation of the walk in freezer, revealed an opened blue plastic bag containing mixed frozen vegetables, with no opened date or date by which the item should be discarded. 2. Further observation during the initial kitchen tour, on [DATE] starting at 8:25 AM, revealed the filter on the juice dispenser was covered with gray matter. 3. Observation on [DATE] at 11:55 AM during the lunch tray line, revealed the same cups of pre-poured portions of juice, tea and milk cups that were in the walk in refrigerator earlier during initial tour without secure covers, were being placed on resident trays. The loose and missing lids were placed on the cups as the drinks were placed on the residents' trays. 4. Observation on [DATE] at 4:50 PM, revealed Cook1 was behind the steam table preparing trays. Cook1 left the steam table going into the clean dish area with gloves on, to obtain clean dishes. She then returned to the steam table without washing hands and changing gloves. During interview with [NAME] 1, on [DATE] at 4:50 PM, she stated she was unaware she could not leave the steam table to go get clean dishes. She then stated, by leaving the steam table and coming back without washing her hands and changing gloves, she could contaminate the food and cause residents to become sick. 5. Review of the facility's policy titled Hair Restraints/Jewelry/Nail Polish, revealed Food and Nutrition Services employees shall wear hair net, hat, or hair restraint at all times. The policy did not address beard nets. Observation on [DATE] at 4:50 PM, revealed Dietary Aide6, who had a beard, was observed plating beans in bowls during tray line without wearing a beard guard or hair net. During interview with Dietary Aide (DA)6, on [DATE] at 6:00 PM, he stated he didn't know he was to wear a beard guard and hair net. However, he stated he could see how by not wearing the beard guard and hair net, hair could fall into the food. He stated he had some training related to dietary sanitation, but couldn't recall when he received the training. 6. Observation on [DATE] at 5:10 PM, revealed Dietary Aide1 placed drinks and utensils on the meal trays during tray line without wearing gloves. Additionally, Dietary Aide1 was observed pulling at or touching mask and/or face. During interview with the Dietary Manager, on [DATE] at 6:15 PM, he stated he had only been in his position for a month, and he was working on getting everything in the kitchen in order. He stated it was his responsibility to make sure all food was dated when opened with the opened date, prior to placing it back in the refrigerators and freezers. Further, he stated any foods or drinks should be sealed properly before placing them in the refrigerators or freezer. Per interview, the cups of pre-poured milk and juice which did not have tight lids and were not properly sealed, should have been disposed of and should not have been served during the lunch meal on [DATE]. Furthermore, he stated the juice dispenser should have been cleaned, and he was working on creating a schedule of duties for kitchen staff. Additional interview with the Dietary Manager, on [DATE] at 9:35 AM, revealed all dietary staff needed to wear a hair net or a hat, and if they had a beard, they were to wear a beard net. In continued interview, he stated it was his expectation food was stored, prepared and served in a sanitary manner to prevent cross contamination. He further stated he had a certification in Serve Safe and Food Handler, and would be training dietary staff on kitchen expectations and infection control. He stated it was his expectation staff followed dietary policies. During interview with the Administrator, on [DATE] at 10:30 AM, she stated it was her expectation dietary staff wore hair nets or hats; and wore beard guards when they had a beard. Further, she stated when dietary staff was working behind the steam table, and moved to another part of the kitchen, they were to wash hands and don new gloves prior to working at the steam table again. In continued interview, she stated dietary staff was to wear gloves when working in the kitchen plating food or placing utensils or drinks on the meal trays. Further, staff was to use good hand hygiene in the kitchen after touching their face or mask. She stated dietary staff was to follow facility dietary policies and regulations related to storing, preparing, and serving food.

Based on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment. Observation during initial tour of the facility, on 07/09/2024 from 8:30 AM until 9:55 AM, revealed resident room doors had scuff marks at the bottom of the doors; resident rooms and bathrooms had scuff marks on the floors; resident rooms had sticky floors, and there was a strong urine odor. This affected Rooms and/or bathrooms for PN9, PN10, PN12 PN13, PN14, PN15, PN16, and PN17. Additionally, observation on 07/09/2024 at 9:15 AM, of the flooring outside Room PN13, revealed the white tile and brown flooring was chipped at the entrance to the room. The findings include: Review of the facility's policy, titled Resident Rights, effective 11/28/2016, revealed the facility must provide residents with a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility's Memorandum on Preventive Maintenance Program, revised 08/18/2014, revealed maintenance staff would check all nurses' stations and housekeeping carts during morning rounds to pick up the Maintenance Request Logs and take care of the requests as time allows. Continued review revealed if an issue was urgent in nature, it would be addressed immediately. Review of the facility's Environment of Care Procedure for Cleaning Residents' Rooms, undated, revealed the facility had a purpose to provide a clean, attractive, and safe environment for residents, visitors, and staff. Continued review revealed the facility used basic disinfectant to clean surfaces and floors. Additionally, housekeeping staff would immerse the mop in the bucket of disinfectant cleaner and wring it out, but the mop should be wet enough to allow the disinfectant cleaner to dwell on the floor, which allowed the disinfectant to work. Observation on 07/09/2024 of Room PN9 at 8:30 AM; Room PN15 at 9:22 AM; and Room PN17 at 9:48 AM, revealed the rooms had sticky floors. Observation on 07/09/2024 of the bathroom in Room PN9 at 8:43 AM; bathroom in PN10 at 8:50 AM; bathroom in PN14 at 9:14 AM; bathroom in PN13 at 9:20 AM; and bathroom in PN15 at 9:24 AM, revealed strong urine odors. Observation on 07/09/2024 of the doors for Room PN10 at 8:44 AM; and PN12 at 9:07 AM, revealed scuff marks on the bottom of both doors. Observation on 07/09/2024 at 9:15 AM, revealed the white tile and brown flooring was chipped at the entrance to Room PN13. Observation on 07/09/2024 at 9:27 AM, of the flooring in Room PN16; and at 9:55 AM, of the bathroom flooring in room PN17, revealed scuff marks on the floors. During interview with Resident (R)12, on 07/09/2024 at 8:34 AM, she stated the floor in her roomwas usually sticky. R12 further stated, they mop it sometimes, but it's dirty water. You can't clean with dirty water. During an interview with R29, on 07/09/2024 at 9:27 AM, she stated the scuff marks on the floor in her room had been there since her admission to the facility in January 2024. R29 stated the staff told her the scuff marks were made when the bed was moved and the wheels of the bed scuffed the floor. During an interview with State Registered Nursing Assistant (SRNA)2, on 07/09/2024 at 8:56 AM, she stated she had seen the scuffed marks and the chipped flooring, but she figured someone else had already reported this and therefore she didn't fill out a work order. SRNA2 stated she could smell the urine smell in rooms on the PN unit. She further stated most residents on the PN unit were able to take themselves to the bathroom and some residents did not flush the commode afterwards, which resulted in the urine scent. During an interview with Licensed Practical Nurse (LPN)3, on 07/10/2024 at 8:56 AM, she stated she had worked in the facility since November 2023 and most of the scuffed areas on the doors and floors had been there since she was hired. Further, she stated she was aware of the chipped tile and flooring. LPN3 stated she had noticed these environmental issues in the facility, and although she had received education related to filling out work orders and turning them in during orientation, she had not filled out a work order on any of these concerns. She further stated she had told housekeeping about the sticky floors and the urine smells and they would clean the resident rooms, but the floors were still sticky. LPN 3 stated she felt the urine smell was due to residents who were incontinent and dribbled on themselves. During interview with LPN4, on 07/10/2024 at 10:05 AM, she stated she was educated in orientation over work orders. LPN4 stated she was trained on how to fill one out, and where to put it for maintenance staff. LPN4 stated she was not aware of the chipped tile and flooring and therefore and not completed a work order for those issues. She further stated she had noticed the sticky floors. LPN4 stated she saw housekeeping sweeping and mopping the floors, but it didn't seem to help with the sticky floors. LPN4 stated she had nasal issues and could not smell any urine scent. During an interview with Housekeeper (HSKP)1, on 07/09/2024 at 10:01 AM, she stated she could smell urine in the hallway and she was in the process of cleaning and mopping. HSKP1 stated she thought the stickiness of the floors was due to the type of disinfectant they had to use on the floors, but she had not reported the issue to anyone because she thought staff knew this about the floors. She stated housekeeping staff cleaned and mopped the resident rooms and bathrooms daily, and at intervals the rooms and bathrooms were deep cleaned which involved moving the furniture around and cleaning everything in the room, and mopping and dusting. HSKP1 stated she had not paid attention to the chipped tile and flooring, but was aware of the scuffed areas on the hallway and in resident rooms. HSKP1 stated the scuff marks were from staff moving the beds in the rooms. During an interview with the Maintenance Director, on 07/12/2024 at 2:06 PM, he stated he had worked in the facility since 2006. He further stated he was also head of housekeeping at the facility. Per interview, the facility had recently implemented the technology for safer environment and life safety compliance (TELS), which was a computer program designed for staff to place work orders for maintenance staff to review what needed repaired in the facility. However, he stated the facility was still using paper work orders during the transition phase. The Maintenance Director stated there were no current work orders for environmental issues in the facility on the TELS system or the paper system. During continued interview with the Maintenance Director, on 07/12/2024 at 2:06 PM, he stated he made rounds daily in the facility, but relied on the floor staff to report any environmental issues. He stated he just mainly looked at the bigger issues for concerns like plumbing or ceiling issues and did not pay attention to the floors which had been chipped. He stated he planned on bringing up these new issues in the next morning meeting with the rest of the team. He stated his staff had recently started painting scuffed areas on the doors, but no other environmental issues were on the table to be fixed at this time. The Maintenance Director stated he tried to spot paint areas monthly, but it did not always happen. In further interview, he stated the housekeeping staff would deep clean two (2) rooms monthly, but would deep clean rooms as needed. He stated deep cleaning involved pulling out all of the furniture and cleaning the floors, dusting the shelves, and cleaning the bathroom commodes along with bathroom flooring. During an interview with the Director of Nursing (DON), on 07/12/2024 at 3:02 PM, she stated she expected the residents to have a safe, clean environment. The DON stated she expected her staff to alert the maintenance staff and the housekeeping staff for any issues, in order for repairs or housekeeping issues to be taken care of in a timely manner. The DON stated she was not aware of any environmental issues in the facility, but the facility did have normal wear and tear as it was an older building. The DON further stated she was unaware of the sticky floors but she was aware of the urine smell which she attributed to routine incontinence care of the residents. During an interview with the Administrator, on 07/12/2024 at 4:20 PM, she stated the residents had the right to a comfortable and clean environment. She stated she made rounds daily in the facility and talked with the residents and staff. The Administrator stated she expected her staff to fill out work orders for any repairs or maintenance needed in order for maintenance staff to address these concerns. When questioned about the sticky floors in resident rooms and bathrooms and the urine scent, she stated housekeeping staff worked hard to keep the facility clean. She stated the residents had the right to a comfortable and clean environment.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) 1 of 34 sampled residents, Resident (R)78 Observation on 07/09/2024 at 9:48 AM, revealed signage on R78's room door, stating Special Droplet/Contact Precautions. Further observation revealed State Registered Nurse Aide (SRNA)3 exited R78's room and removed her mask and gown in the hallway, and then carried the soiled mask and gown across the hall. She then used her gloved hand to engage the keypad to open the door to the room labeled Men's Shower/Biohazard, where she disposed of the soiled mask, gown, and gloves in a trash receptacle in the room. The findings include: Review of the facility policy titled, Infection Control/Isolation Guidelines effective date 02/14/2023 and last revised 04/12/2024, revealed for any type of precaution, remove gown and gloves and perform hand hygiene prior to exiting the resident's environment/room. Review of the facility policy titled, Use of Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected Covid-19, issued by the Centers for Disease Control (CDC), dated 06/03/2020, revealed the three (3) step process for Doffing (taking off the gear), included: 1) remove gloves, 2) remove gown and 3) Health Care Professional may now exit the patient room. Review of R78's medical record Face Sheet, revealed the facility admitted the resident on 10/03/2023 with diagnoses including metabolic encephalopathy, severe protein-calorie malnutrition, and major depression. Review of R78's Physician's Orders, dated 06/27/2024, revealed orders for Transmission Based Contact/Droplet Isolation-COVID-19. Review of R78's laboratory data, dated 07/02/2024, revealed a positive Covid-19 result. Observation on 07/09/2024 at 9:48 AM, revealed signage on R78's room (E-09) door, stating Special Droplet/Contact Precautions. Further, the signage stated, only essential personnel should enter this room. If you have questions, ask the nursing staff. Everyone, including visitors, doctors and staff must: Clean hands when entering and leaving the room. Wear a mask: (Fit tested N-95 or higher required when performing aerosol-generating procedures). Wear eye protection (face shield or goggles). Gown and glove at the door. Keep the door closed. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. Further observation on 07/09/2024 at 9:48 AM, revealed SRNA3 exited R78's room and removed her mask and gown in the hallway, and then carried the soiled mask and gown across the hall, and used her gloved hand to engage the keypad to open the door to the room labeled, Men's Shower/Biohazard. She then disposed of the soiled mask, gown, and gloves in a trash receptacle in the room, and washed her hands. During interview, on 07/09/2024 at 9:48 AM, with SRNA3, she stated she had worked at the facility for three (3) months and was educated on infection control, but could not remember the guidance on whether she should remove the Personal Protective Equipment (PPE) before exiting an isolation room or after exiting the room. SRNA3 further stated she disposed of her PPE including gown, mask and gloves in the regular trash can in the shower/biohazard room. She stated she knew she was supposed to discard her gloves prior to using the key pad. She stated she did wash her hands immediately after removing her gloves. During a follow up interview, on 07/11/2024 at 9:00 AM, with SRNA3, she stated since speaking with the State Agency Representative on 07/09/2024, she had gone to her supervisor to ask for clarification related to removing PPE, and was informed PPE was to be removed inside the room prior to exiting. SRNA3 further stated, normally she would have thrown the PPE in the trash just outside the door way, but when she exited the room the trash bin was gone so she had to take the soiled PPE to the biohazard room. She stated she should have removed her mask, gown and gloves and then washed her hands prior to exiting room E-09. During interview on 07/10/2024 at 5:05 PM, with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), she stated staff should don PPE prior to entering a Covid positive room, and after providing care, remove the soiled PPE including mask, gown, and gloves, and place it in the garbage can inside the room. The ADON further stated, biohazard cans were no longer mandatory for disposing COVID PPE. Per interview, after doffing PPE in an isolation room, staff should exit the room, and then use the closest hand sanitizer to perform hand hygiene. She stated it was not acceptable for staff to exit an isolation room wearing PPE, and remove it outside the room. During further interview, on 07/10/2024 at 5:05 PM. with the ADON/IP, she stated staff should never wear gloves out in the hall, and it was not acceptable to wear gloves when coming out of any precaution room because staff could cross contaminate objects such as door knobs, and through cross contamination, could cause other residents, visitors or staff to become ill. She stated if she saw staff coming out of an isolation room wearing dirty gloves, she would write the staff member up. She stated she educated all new hires on how to don and doff PPE during orientation, but she did not check them off until they had worked on the floor a few days and then she would audit them. In further interview, she stated sometimes due to her busy schedule, she did not get to audit all staff members. During an interview, on 07/12/2024 at 2:42 PM, with the Administrator, she stated it was her expectation all facility infection control policies and regulations be followed and all staff be [NAME] related to infection control guidelines to prevent the spread of infection.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food preferences were honored for one (1) of eight (8) sampled residents (Resident #8) related to his/her food dislikes and preferred food/drink requests. The findings include: Review of the facility's policy titled, Resident Diet History and Food Preference Guidance, dated 05/09/2023, last reviewed 02/14/2024, revealed, All residents would be interviewed for a diet history with food and beverage preferences documented. Continued review revealed tray enhancements such as high-calorie, high-protein foods, fortified foods, and other food interventions were to be initiated as needed to maintain nutritional parameters. Further review revealed Food and beverage preferences would be noted on the tray ticket and honored at meal services when possible. Record review revealed the facility admitted Resident #8 on 11/21/2022, with diagnoses of other diseases of the Pancreas, dysphagia, and spondylosis. Continued review of Resident #8's record revealed a physician's order for the resident to receive a regular texture diet with thin liquids. Further record review revealed no documented evidence of a contraindication for the resident to receive orange juice. Review of the breakfast menu for 03/14/2024 revealed bacon listed as the only meat on the menu. Review of the temperature logs for 03/14/2024 revealed no documentation noting sausage patties were listed, the only sausage noted was ground sausage and pureed sausage. Review of Resident #8's tray card dated 03/14/2024, revealed for breakfast, daily the resident was to receive milk, orange juice, yogurt, fruit, fortified foods, toast, and sausage. However, observation on 03/14/2024 at 8:35 AM, revealed Resident #8's breakfast tray contained a French toast slice, bacon, cottage cheese, a cup of fruit, milk, and a red liquid in a glass. Further observation revealed no visual evidence of the resident's preferred orange juice or sausage. Review of Resident #8 's tray card dated 03/15/2024 revealed breakfast daily: milk, orange juice, yogurt, fruit fortified foods, and bacon. However, observation on 03/15/2024 at 8:40 AM, of Resident #8's meal tray revealed eggs, a slice of toast, gelato (a type of ice cream), and orange juice. Further observation revealed no visual evidence of the resident's preferred sausage. In interview with Resident #8 on 03/14/2024 at 8:35 AM, the resident stated he/she had notified staff of his/her dislike of bacon and had requested to have sausage only. Resident #8 stated he/she continued receiving bacon on his/her tray frequently in spite of his/her requests. The resident stated he/she had also requested orange juice on his/her tray for meals, but only received the orange juice occasionally. Resident #8 further stated he/she did not want and had requested not to have cottage cheese and fruit for breakfast, but continued to receive those foods on his/her breakfast tray. During an interview with the Regional Dietary Manager (DM) on 03/15/2024 at 4:00 PM, he stated he was aware residents' food preferences should be honored if at all possible. He stated if a resident's choice and preference was for sausage, rather than bacon, there was always the availability of bacon and sausage every morning to meet that choice. The Regional DM stated he was not certain why Resident #8's tray card had sausage listed, but staff had placed bacon on the tray instead. The Regional DM stated the facility's process was for residents' dietary orders and preferences to be placed into the computer system, and from there the resident's tray card was printed with each meal for staff to know what to place on their tray. During an interview with the Administrator (ADM) on 03/15/2024 at 4:30 PM, she stated she expected residents' preferences to be honored. She stated the contracted agency staff for the kitchen was a pilot program that started in November, and she was uncertain of how long the pilot program was to be in place. The ADM further stated the prior Dietician left last week, and the Regional DM was the facility's interim at that time.

Based on interview, record review, review of the facility's policy, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated 10/01/2019, it was determined the facility failed to develop a person-centered comprehensive care plan (CCP), which included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs for one (1) of fourteen (14) sampled residents (Resident #1). Upon admission, on 04/18/2022, the facility assessed Resident #1 to be At risk for elopement. However, the facility failed to develop Resident #1's care plan to include person centered interventions that included supervision and monitoring. On 05/04/2022, Resident #1 eloped (exited the facility without staff knowledge)from the facility and was found in a parked vehicle, located in the facility's parking lot. The vehicle was approximately eighty-five (85) feet from the facility. The facility's failure to have an effective system in place to ensure each resident's care plan was developed and implemented with interventions to reduce or prevent the likelihood of an elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/27/2022 and was determined to exist on 05/04/2022, in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop and Implement the Care Plan at a Scope and Severity (S/S) of a J; and, at 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a J. Substandard Quality of Care was identified at F-689. The facility was notified of the Immediate Jeopardy (IJ) on 05/27/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 06/06/2022, alleging the IJ was removed on 05/19/2022, and alleging the facility had achieved substantial compliance on 05/21/2022. The State Survey Agency determined the IJ had been removed on 05/19/2022, as alleged, and substantial compliance had been achieved on 05/21/2022, as alleged, prior to the State Survey Agency's entrance, on 05/24/2022. The deficient practice was determined to be past non-compliance with a compliance date of 05/21/2022. The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated 10/01/2019, revealed the comprehensive care plan (CCP) was an interdisciplinary communication tool. The RAI stated the CCP must include measurable objectives and time frames and must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's policy titled, Care Plan Completion, pages 2-42 of the RAI 3.0 User's Manual Version 1.17.1, dated 10/01/2019, revealed the facility was to evaluate information gained through assessment to identify problems, causes, contributing factors, and risk factors to develop a care plan that addressed those findings. Review of Resident #1's medical record revealed the facility admitted the resident, on 04/18/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/24/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15). This score indicated the resident had severe cognitive impairment. Further review of Resident #1's MDS Admission Assessment revealed the resident was ambulatory without need of assistive devices, but required the physical assistance of one (1) person to walk in the corridors and for locomotion on the unit and off the unit. Continued review of Resident #1's medical record revealed, on 04/18/2022 at admission, the facility assessed Resident #1 to be at risk for elopement related to his/her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed the Nurse's Notes, dated 04/18/2022, documented a Wander Guard was placed on Resident #1's right ankle. Record review revealed the Wander Guard was checked every shift starting 04/18/2022. Review of Resident #1's care plan, initiated on 04/18/2022, revealed a focus area of At Risk for Elopement. Further review of the care plan revealed interventions that included: attempt reorientation as needed; involve in activities of preference as tolerated, which included coloring, food socials, talking, and reminiscing about life; redirect wandering as needed; use the Wander Guard per the order; ensure Wander Guard was functioning properly; and, change the Wander Guard device every ninety (90) days, as indicated. However, there were no documented interventions to indicate the level of supervision and monitoring staff was to provide. Review of the facility's Incident Report about Resident #1's elopement, dated 05/04/2022, revealed an exit door alarm sounded between 9:00 AM and 9:30 AM on 05/04/2022. However, there was no record to pinpoint the exact time of the alarm. An Occupational Therapist (OT) was entering the hall where the alarm sounded to give therapy to a resident. Per the report, the OT attempted to silence the alarm but was not successful. At that time, the Assistant Director of Nursing (ADON) came to that hallway and silenced the alarm. Further review of the incident report revealed a Code 99 (overhead message to conduct a resident count to ensure the location of all residents) was not called, and a head count of the residents was not done. The report stated Resident #1 was found in the facility's parking lot, sitting in the Director of Maintenance's (DOM) vehicle, by the DOM, around 10:30 AM. Resident #1 was returned to the facility with no apparent injuries. Interview with the Assistant Director of Nursing (ADON), on 05/27/2022 at 11:25 AM, revealed she thought the intervention of one-to-one (1:1) supervision as needed was specific enough for staff to follow. In addition, she stated she thought increased supervision as indicated was specific enough for staff to follow. The ADON stated she was addressing this because on admission Resident #1 was exhibiting exit seeking behaviors and could have had these interventions in the resident's care plan. Interview with the MDS Coordinator, on 05/26/2022 at 1:00 PM, revealed care plans should be specific to the resident's needs. Further interview revealed one-to-one (1:1) supervision meant if a resident started to exhibit exit seeking behaviors, he/she should be with a staff member at all times. She stated the Wander Guard assisted with supervision, but it was not the only intervention for elopement risk. Interview with the Director of Nursing (DON), on 05/27/2022 at 11:02 AM, revealed the MDS Coordinator developed the care plans, and she was not involved. She stated it would be beneficial to develop care plans that specified what type of supervision a resident needed, such as with Resident #1. Further interview revealed it would not hurt to specify the frequency of supervision. Interview with the Administrator, on 05/27/2022 at 11:25 AM, revealed care plans should be personalized to the individual. She stated it was hard to determine what type of supervision a resident needed. Further interview revealed she expected staff to initiate changes as needed for the care plan, and the care plan should be changed frequently, if needed. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 06/06/2022 that alleged removal of the IJ, on 05/19/2022, and that substantial compliance was achieved on 05/21/2022. Review of the IJ Removal Plan revealed the facility implemented the following: 1. Resident #1 was put on one-to-one (1:1) supervision immediately on 05/04/2022 and downgraded to fifteen (15) minute checks following an Interdisciplinary Team (IDT) review at 7:00 PM on 05/04/2022. The resident remained on every fifteen (15) minute checks for the next three (3) weeks and was decreased to thirty (30) minute checks following an IDT review on 05/24/2022. Resident #1's comprehensive plan of care was updated throughout this process. The IDT consisted of at least three (3) of the following team members: Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Activities Director, Dietary Director, Director of Therapy, Director of Maintenance (DOM), Business Office Director, Human Resources Director, Social Services Director, Admissions Director, Licensed Nursing staff, and Certified Nursing staff. 2. A head-to-toe assessment was completed on Resident #1 on 05/04/2022 by a unit nurse. No issues were noted. 3. An investigation was initiated and an incident report was completed by the Unit Nurse on 05/04/2022, and a self-reportable incident was completed and submitted to the Office of Inspector General (OIG/State Survey Agency) and Adult Protective Services (APS) by the DON and the NHA on 05/04/2022. During the investigation, interviews were conducted, on 05/04/2022 by the DON, and witness statements were obtained from all witnesses. 4. A facility wide maintenance check was completed by the DOM to ensure Wander Guards and doors were functioning appropriately on 05/04/2022. All Wander Guards and doors were functioning appropriately. In addition, the facility created and implemented daily audits log for all exit doors on 05/05/2022. 5. On 05/04/2022, all exit doors were locked down by the DOM. These exit doors were not to be used as entrance and exit except for fire exit release during an emergency. All staff and visitors must go in and out of the main entrance. The main entrance was keypad locked and had a door screener present from 7:00 AM to 7:00 PM. In addition, all exit doors had DO NOT EXIT signs posted on them on 05/04/2022 by the DOM. 6. One-to-one (1:1) supervision in-servicing, and following policies and procedures education was conducted by the Regional Nurse Consultant (RNC) for the ADON on 05/04/2022. Also, one-to-one (1:1) supervision in-servicing, and following policies and procedures education was conducted by the Director of Therapy for the OT on 05/04/2022. 7. The facility created and started an all-staff in-service to review the elopement policy, and specifically, what to do when an alarm sounded in the facility. Each participant was required to pass a post-test to ensure competency. Education was initiated on 05/04/2022, and one-hundred percent (100%) of staff was educated by 05/13/2022. Any new staff members, agency staff, or staff on leave were required to have education prior to starting their shift. This education would be completed by the Human Resource Director, the Administrator, or Licensed Nursing Management Designee. 8. The Quality Assurance and Performance Improvement (QAPI) Committee met to discuss a plan for education of staff and systemic changes put in place on 05/05/2022 and approved them. Education, elopement drills, and new audits were reviewed. The QAPI Committee included the DON, the Medical Director, the Assistant Director of Nursing (ADON), the NHA, the Social Services Director, and the Activities Director. 9. Elopement books were updated, pictures of all elopement residents were enlarged, and an elopement book was added at the main entrance on 05/05/2022. This was completed by the Administrator and Social Services Director (SSD). Also, audits in place for Elopement Binders were to be checked by the SSD. Audits were to be done weekly for twelve (12) weeks. 10. The facility implemented elopement drills conducted by the DOM, which continued every shift for two (2) weeks to ensure all staff would be involved in more than one (1) elopement drill. These drills were completed from 05/05/2022 to 05/18/2022. 11. The RNC met with Care Plan team members (MDS Coordinator, DON, ADON, SSD, and Activities Director), on 05/06/2022, to educate on the importance of personalized care plans and that they must be individualized to meet each resident's needs. 12. On 05/12/2022, the equipment for fourteen (14) of fourteen (14) residents identified as At risk for elopement had their Wander Guard equipment checked by administrative nursing staff to make sure the equipment was in place and functioning appropriately. No concerns were identified. 13. The IDT met, on 05/12/2022, and reviewed fourteen (14) residents' clinical records, that were assessed as At risk for elopement, to update their CCP, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT included the ADON, MDS Coordinator, SSD, and Activities Director. The IDT conducted the reviews to ensure the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Each resident's care plan was revised to include individualized activities and supervision to meet their individual needs regarding their risk for elopement. 14. On 05/13/2022, the QAPI Committee met and reviewed that one-hundred percent (100%) of education was completed for staff. New staff, agency staff, and any staff on leave would be educated by HR/Nurse Management Designee prior to start of their work shift. Elopement drills had been completed to date and would continue to 05/18/2022 to complete two (2) weeks of drills on each unit. 15. Black floor mats were ordered and placed next to each door, on 05/17/2022, as a deterrent for residents to exit. 16. On 05/20/2022, the QAPI Committee met to review and approve the IJ Removal Plan. The Committee also determined the facility would allege they had achieved substantial compliance as of 05/21/2022. The QAPI Committee found that audits of At risk for elopement residents were in place, elopement binders were updated and being audited weekly, all elopement drills were completed daily, each shift for two (2) weeks and would continue once a week for the next four (4) weeks. The Medical Director approved the actions taken. In addition, the QAPI Committee will meet weekly to discuss audits in place, education outcomes, and any issues that arise for the next twelve (12) weeks. The State Survey Agency validated the implementation of the facility's IJ Removal Plan and substantial compliance as follows: 1. Resident #1 was put on one-to-one (1:1) supervision immediately on 05/04/2022 and downgraded to fifteen (15) minute checks following an IDT review at 7:00 PM on 05/04/2022. The resident remained on every fifteen (15) minutes checks for the next three (3) weeks and was decreased to thirty (30) minute checks following an IDT review on 05/24/2022. The IDT included the Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Activities Director (DOA), Dietary Director (DM), Therapist Director (RM), Director of Maintenance (DOM), Business Office Manager (BOM), Human Resources Director (HR), Social Service Director (SSD), Admissions Director (AD), and Licensed and Certified Nursing staff. Review of Resident #1's medical record revealed his/her Comprehensive Care Plan (CCP) was updated throughout this process. Review of the facility's investigation into the 05/04/2022 elopement incident revealed on 05/04/2022, Resident #1 was put on one-to-one (1:1) supervision. Review of Resident #1's CCP revealed fifteen (15) minute checks were initiated following the incident. Review of Resident #1's medical record revealed an Incident Note, on 05/04/2022 at 7:00 PM (late entry) that stated the resident was on one-to-one (1:1) supervision. Record review revealed, following an IDT review, on 05/04/2022 at 7:00 PM, Resident #1 was downgraded to every fifteen (15) minute checks for three (3) weeks. Following an IDT review on 05/24/2022, Resident #1's supervision was downgraded to every thirty (30) minute checks. On 05/28/2022, every fifteen (15) minute checks were initiated. Resident #1's CCP was updated throughout the process to reflect changes in supervision. Continued review of the Quality Assurance and Performance Improvement (QAPI) Committee meeting documentation revealed Resident #1's CCP was reviewed and updated, on 05/04/2022, by the DON, ADON, and the Minimum Data Set (MDS) Coordinator. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed Resident #1 was placed on one-to-one (1:1) supervision immediately after the incident. Per the DON, one-to-one (1:1) supervision meant that a staff member had eyes on the resident at all times. Resident #1 remained on one-to-one (1:1) supervision for the remainder of the 7:00 AM to 7:00 PM shift on 05/04/2022. The DON stated the IDT met and reviewed Resident #1's behavior assessment and recommended to downgrade Resident #1's supervision to every fifteen (15) minute checks. She stated Resident #1 remained on every fifteen (15) minute supervision until 05/24/2022, when the IDT recommended to downgrade Resident #1's supervision to once every thirty (30) minutes. The DON stated, on the recommendation of the Regional Nurse Consultant (RNC), on 05/28/2022, all residents assessed as At risk for elopement were placed on every fifteen (15) minute checks. Further interview revealed Resident #1's CCP was updated by the DON, ADON, and the MDS Coordinator throughout the process to reflect changes in supervision. Interview with the RNC, on 06/07/2022 at 4:47 PM, revealed on 05/04/2022 Resident #1 eloped. The RNC stated the DON assessed Resident #1 and initiated one-to-one (1:1) supervision of the resident. According to the RNC, Resident #1 was on one-to-one (1:1) supervision for the remainder of the shift, at which time the IDT reviewed Resident #1's assessment and placed him/her on every fifteen (15) minute checks. The RNC stated on 05/28/2022, after review of the Comprehensive Care Plans, for residents assessed as At risk for elopement, she recommended these residents be placed on every fifteen (15) minute checks. Interview with Patient Care Assistant (PCA) #1, on 06/07/2022 at 11:26 AM, revealed that she and other designated staff monitored residents At risk for elopement as ordered on both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts. She stated all resident checks were documented on the twenty-four (24) hour sheets, which were kept in a binder and scanned into the resident's chart. 2. Review of Resident #1's medical record revealed a head-to-toe assessment was performed, on 05/04/2022 at 10:45 AM, by Registered Nurse (RN) #1. No injuries were noted. Interview with RN #1, on 06/06/2022 at 2:23 PM, revealed she performed a head-to-toe assessment on Resident #1 immediately following the elopement incident on 05/04/2022. RN #1 stated there were no injuries or symptoms of distress. 3. Review of the facility's investigation of the 05/04/2022 elopement incident revealed the incident report was completed by RN #2. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed that she and the NHA completed and submitted a self-reportable incident report to OIG (Office of Inspector General/State Survey Agency) on 05/04/2022. Further review revealed the DON conducted interviews, and witness statements were obtained from Licensed Practical Nurse (LPN) #2, DOM, ADON, RM, and Occupational Therapy (OT). 4. Review of the facility's investigation into the 05/04/2022 elopement incident revealed that a facility-wide maintenance check was completed by the DOM to ensure Wander Guards and exit doors were functioning appropriately on 05/04/2022. Review of the Daily Alarm Check Log sheets, from 05/04/2022 to 06/07/2022, for all twelve (12) exit doors, revealed an inspection was conducted and the system passed. Interview with the DOM, on 06/06/2022 at 2:43 PM, revealed that all doors and Wander Guards were functioning appropriately. He stated that he did a daily inspection of all door alarms and functionality of the residents' Wander Guard alarm systems. The DOM stated there were twelve (12) exit doors, and each inspection included checking the magnetic locks, the wandering resident alarm systems, the door station alarms, and the remote alarm monitors. He stated the inspections, which began on 05/04/2022, were documented on the Daily Alarm Check Log sheets. He stated each of the twelve (12) outside exit doors were alarmed, and staff must input a code onto the keypad to disarm the alarm. Interview with the DON, on 06/07/2022 at 4:47 PM, revealed facility wide maintenance checks consisted of using a Wander Guard to set off the alarm. She stated each inspection was performed by the DOM and included checking the magnetic locks, wandering resident alarm systems, door station alarms, and the remote alarm monitors. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed the DOM daily audited the Wander Guard system to ensure all doors and Wander Guards were functioning appropriately. The NHA stated each inspection of the exit doors included checking the magnetic locks, the alarm systems, door station alarms, and the remote alarm monitors. Telephone interview with the Medical Director, on 06/07/2022 at 4:33 PM, revealed the facility audited the operation of the exit door alarms daily. 5. Observation of the main entrance revealed the screener sat at the main entrance door, on 06/06/2022 at 11:30 AM, and at multiple observations, on 06/06/2022 and 06/07/2022. The screener was observed screening all persons who entered the facility for COVID-19 and observing all persons that exited the facility. Observation of the facility's twelve (12) exit doors with the DOM, on 06/06/2022 at 10:15 AM, revealed all twelve (12) doors had been locked and a Do Not Exit sign was posted at each door. The doors could be opened for a fire exit in the event of an emergency. Continued observation revealed all doors were locked from the outside, and a code was needed to exit. Also, the alarm sounded when the bar was pushed if the code was not pressed. Interview with the DOM, on 06/06/2022 at 2:43 PM, revealed he locked down all exit doors, and a Do Not Exit sign was posted at each door. He stated these exit doors were not to be used as entrance and exit except for fire exit release during an emergency. The DOM stated there were twelve (12) exit doors. He stated all staff and visitors must go in and out of the main entrance. The DOM stated the main entrance was keypad locked and had a door screener present from 7:00 AM to 7:00 PM. Interview with the Screener, on 06/07/2022 at 9:44 AM, revealed the main entrance was monitored seven (7) days a week from 7:00 AM to 7:00 PM. The Screener stated the Activities Department covered for the Screener for breaks. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed all exit doors were locked down by the DOM and had a Do Not Exit sign placed. The NHA stated the exit doors were not to be used as entrance and exit except for fire exit release during an emergency. Continued interview revealed all staff and visitors must go in and out of the main entrance door, which was keypad locked and had a door screener present from 7:00 AM to 7:00 PM. She stated staff had been educated to use the main entrance for entering and exit. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed during the hours of 7:00 PM to 7:00 AM, the nurse on duty answered the main entrance bell. She stated the nurse must go to the door to let the visitor or staff into the building. 6. Interview with the RM, on 06/07/2022 at 2:45 PM, and the ADON, on 06/07/2022 at 3:27 PM, revealed, on 05/04/2022, both received one-to-one (1:1) supervision education provided by the RNC. Both stated the RNC also educated them on following the facility's elopement policies and procedures. Interview with the RNC, on 06/07/2022 at 4:49 PM, revealed it was determined that the root cause analysis (RCA) of the elopement revealed staff failed to follow the facility's policy and procedure on elopement. The RNC stated, based on the findings of the RCA, the RM and the ADON were given one-to-one (1:1) supervision education on the facility's elopement policies and procedures, which highlighted the importance of following elopement protocols to ensure the residents' overall well-being and safety. 7. Review of the Elopement Education sign-in sheets, dated 05/04/2022, revealed eighty-nine (89) staff were in-serviced on policy and procedure for elopement. Specific education focused on what to do when an alarm sounded in the facility and doing a head count of all residents. Review of the in-service attendance sheet, dated 05/13/2022, revealed the DON and ADON attended a teleconference in-service, facilitated by the RNC, which focused on the facility's elopement protocol. The sheet was reviewed by the NHA. Interview with MDS Assessment Nurse, on 06/06/2022 at 4:30 PM, revealed she had participated in elopement training. She stated a pre and posttest focusing on elopement protocols was given, and she passed the test. Interview with the AD, on 06/06/2022 at 4:37 PM, revealed she was involved in creating an in-service to educate all staff regarding the facility's elopement policy and procedures. Per the interview, the AD participated in an in-service, on 05/04/2022, which focused on the facility's elopement protocol and what to do when an alarm sounded in the facility. She stated a pre and posttest focusing on elopement protocols was given, and she passed the test. Interview with Dietary Aide (DA) #1, on 06/06/2022 at 4:57 PM; the Screener, on 06/07/2022 at 9:44 AM; Dietary Aide (DA) #3, on 06/07/2022 at 10:36 AM; the Dietary Manager, on 06/07/2022 at 10:46 AM; PCA #1, on 06/07/2022 at 11:02 AM; SRNA #7, on 06/07/2022 at 11:31 AM; DA #4, on 06/07/2022 at 12:01 PM; DA #5, on 06/07/2022 at 12:10 PM; SRNA #13, on 06/07/2022 at 1:40 PM; SRNA #5, on 06/07/2022 at 1:47 PM; SRNA #9, on 06/07/2022 at 1:52 PM; Housekeepers #2, #3, #4, and #5, on 06/07/2022 at 1:58 PM; OT, PT, and Speech Therapy (ST), on 06/07/2022 at 2:08 PM; SRNA #10, #11, and #12, on 06/07/2022 at 2:23 PM; the SSD, on 06/07/2022 at 1:53 PM; and the HSC DOA, on 06/07/2022 at 3:11 PM revealed all had been educated on elopement protocols, to use the main entrance only, and elopement drill procedures. All stated they had taken a posttest and passed. Interview with the ADON, on 06/07/2022 at 3:27 PM, revealed she participated in a facility-wide elopement in-service on 05/04/2022 and 05/13/2022, which educated staff on the steps to take if an elopement occurred. She stated the education stressed not assuming the resident by the door was the one who set off the alarm and doing a resident head count. The ADON stated she educated staff on the policies and procedures for elopement. Furthermore, she assisted with educating staff who were absent on the days of the regular educational in-service. She stated all new staff and agency staff were required to have education prior to working his/her shift. She stated new staff would go through an elopement drill in orientation with the DOM. The ADON stated agency staff received a packet with all elopement protocols when they started. She stated the nursing manager was responsible to ensure agency staff completed the elopement education. She stated that staff education began on 05/04/2022, and one-hundred percent (100%) of the staff were educated by 05/13/2022. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed she facilitated a facility-wide elopement in-service, which educated staff on the steps to take if an elopement occurred. She stated that staff education began on 05/04/2022, and one-hundred percent (100%) of the staff were educated by 05/13/2022. The DON stated the education stressed not assuming the resident by the door was the one who set off the alarm and doing a resident head count. She stated all staff took a pre-training test and were required to pass a posttest focusing on elopement protocols. Interview with the RNC, on 06/07/2022 at 4:49 PM, revealed she in-serviced the DON and the ADON on 05/13/2022 related to elopement protocols. She stated that staff were taught not to assume that the resident near the exit wearing a Wander Guard was the one who set off an alarm. She stated she stressed that a head count of all residents must be completed during an elopement. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed she was involved in the review of the facility's elopement policy and procedures and the process for educating all staff. Per the interview, the NHA stated all new staff received education on the facility's elopement policy in orientation. She stated all new staff and agency staff were required to have education prior to working his/her shift. Per the NHA, new staff also went through an elopement drill in orientation with the DOM. She stated the ADON was to ensure agency staff received a packet with all elopement protocols when they started; then agency staff would be educated by the Staff Development Coordinator (SDC) and the ADON. She stated that staff education began on 05/04/2022, and one-hundred percent (100%) of staff were educated by 05/13/2022. Telephone interview with the Medical Director, on 06/07/2022 at 4:33 PM, revealed the facility facilitated the education of staff about the Elopement Policy through in-service education and elopement drills. 8. Review of the 05/05/2022 QAPI Committee meeting agenda and sign-in sheet revealed the QAPI Committee met to discuss the plan for education of staff and approve systemic changes to put in place, which included education, elopement drills, and new audits. The QAPI Committee included the Medical Director, NHA, DON, ADON, SSD, and Admissions Director (AD). Interview with the AD, on 06/07/2022 at 1:39 PM, revealed she was involved in the 05/05/2022 QAPI meeting, which discussed the plan for education of staff and systemic changes. Interview with the SSD, on 06/07/2022 at 1:53 PM, revealed she was a member of the QAPI Committee. She stated the QAPI Committee met on 05/05/2022 to discuss education and systemic changes to include using the main entrance for exit and entry and locking the twelve (12) exit doors to in and out traffic. Interview with the HR, on 06/07/2022 at 2:15 PM, revealed the QAPI Committee met on 05/05/2022 to discuss education and systemic changes. She stated she was involved in educating all new hires. Interview with the DOM, on 06/07/2022 at 2:27 PM, revealed he was part of the QAPI Committee. He stated he met on 05/05/2022 to discuss education and systemic changes. The DOM stated that systemic changes, such as using the main entrance for exit and entry, locking the twelve (12) exit doors to in and out traffic, and placing DO NOT EXIT signs on the doors, were discussed. Interview with the RM, on 06/07/2022 at 2:45 PM, and the HSC DOA, on 06/07/2022 at 3:11 PM, revealed both participated in the 05/05/2022 QAPI team meeting to discuss plans for education of staff and systemic changes that needed to be placed. Both stated they agreed with the QAPI Committee's plan for education and systemic changes. Interview with the ADON, on 06/07/2022 at 3:27 PM, revealed the QAPI Committee met on 05/05/2022 to discuss education and systemic changes related to the recent elopement. She stated the team talked about plans for education of the staff, elopement drills, what to do when a door alarm was triggered, announcing a Golden Alert (same as Code 99) and performing a resident head count. She stated the team discussed staff participation and responsibilities for each part of the drill. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed the QAPI Committee met on 05/05/2022 to discuss education and systemic changes. She stat [TRUNCATED]

Based on observation, interview, record review, review of the website World Weather Online, and review of the facility's policies, it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents (Resident #1) was provided a safe environment. The facility also failed to ensure each resident received adequate supervision and monitoring to prevent elopement. Additionally, the facility did not follow their elopement policy by failing to call a Code 99 to ensure an accounting of all residents in response to the exit door alarm sounding on 05/04/2022. The facility's failure to have an effective system in place to ensure an accounting of all residents after a door alarm sounded to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/27/2022 and was determined to exist on 05/04/2022, in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop and Implement the Care Plan at a Scope and Severity (S/S) of a J; and, at 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a J along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on 05/27/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 06/06/2022, alleging the IJ was removed on 05/19/2022, and alleging the facility had achieved substantial compliance on 05/21/2022. The State Survey Agency determined the IJ had been removed on 05/19/2022, as alleged, and substantial compliance had been achieved on 05/21/2022, as alleged, prior to the State Survey Agency's entrance, on 05/24/2022. The deficient practice was determined to be past non-compliance with a compliance date of 05/21/2022. The findings include: Review of the facility's policy titled, Policy and Procedure Regarding Missing Residents and Elopement, not dated, revealed when no reason could be found for the sounding of the door alarm, a Code 99 would be announced over the public address system, and a facility head count would be initiated. Review of the facility's policy titled, Policy and Procedure for Personal Safety Devices for Residents at Risk of Elopement, not dated, revealed all residents were provided adequate supervision to meet each resident's nursing and personal care needs. Per the policy, all residents would be assessed for behaviors or conditions that put them at risk of elopement. Record review revealed the facility admitted Resident #1, on 04/18/2022, with diagnoses that included Alzheimer's Disease and Dementia. Upon admission, the facility assessed Resident #1 as At risk for elopement related to his/her diagnosis of Alzheimer's Disease. In addition, the facility assessed Resident #1 to exhibit wandering and exit seeking behaviors. Review of Resident #1's Admission Minimum Data (MDS) Assessment, dated 04/24/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated severe cognitive impairment. Further review of Resident #1's Admission MDS Assessment revealed the resident was ambulatory without need of assistive devices. However, per the assessment, Resident #1 required the physical assistance of one (1) staff for walking in the corridors and locomotion on and off the unit. Review of Resident #1's care plan, dated 04/18/2022, revealed the resident was care planned for elopement risk with interventions that included: attempt reorientation as needed; involve in activities of preference as tolerated, which included coloring, food socials, talking, and reminiscing about life; redirect wandering as needed; use the Wander Guard per the order; ensure Wander Guard was functioning properly; and, change the Wander Guard device every ninety (90) days, as indicated. Review of the facility's Incident Report related to Resident #1's elopement, dated 05/04/2022, revealed between 9:00 AM and 9:30 AM (no record of the exact time), the exit door alarmed, on the HSC Short Hall. The Occupational Therapist (OT) was near the door that alarmed. The OT redirected a resident away from the door and, attempted to silence the alarm. Per the report, the Assistant Director of Nursing (ADON) then came and silenced the alarm but did not initiate a Code 99 (overhead message to conduct a resident count to ensure the location of all residents) and/or conduct an accounting of all the residents. Further review revealed on 05/04/2022, around 10:30 AM, the Director of Maintenance (DOM) went to his vehicle to leave the facility. The DOM's vehicle was eighty-five (85) feet from the exit door. Per the report, he found Resident #1 sitting in the front seat on the passenger side of his vehicle. The DOM and the Administrator assisted Resident #1 back into the building without incident. In addition, the report stated a head-to-toe assessment was completed by Registered Nurse (RN) #1, and no issues were identified. Further review revealed Resident #1 was immediately placed on one-to-one (1:1) monitoring for the remainder of the shift which ended at 7:30 PM on 05/04/2022. Review of the Daily Alarm Check Log sheet, dated 05/04/2022, which included all twelve (12) exit doors, revealed an inspection was conducted and the system passed. Observation of the elopement route with the DOM, on 05/25/2022 at 8:30 AM, revealed there was a concrete sidewalk from the exit door to his vehicle which was the second vehicle in the parking lot. The sidewalk had a slight incline. The DOM measured the route at this time, and the route was eight-five (85) feet. Review of the website World Weather Online, https://www.worldweatheronline.com, revealed the weather conditions at the facility, on 05/04/2022 between 9:00 AM and 12:00 PM were: temperature of sixty-four (64) to sixty-six (66) degrees Fahrenheit; cloudy skies; and wind speed of five (5) to six (6) miles per hour, with gusts up to eight (8) miles per hour. Interview with the Director of Maintenance (DOM), on 05/25/2022 at 8:30 AM, revealed he went to his vehicle, on 05/04/2022 around 10:30 AM, and discovered Resident #1 sitting on the passenger seat of his vehicle. Further interview revealed Resident #1 was calm and did not show any signs of distress. The DOM stated he phoned the Administrator, and she and the Director of Nursing (DON) came out and assisted the resident back into the building. Interview with the Occupational Therapist (OT), on 05/25/2022 at 10:58 AM, revealed she arrived on the HSC Short Hall, on 05/04/2022 about 9:30 AM, to begin Resident #7's therapy. She stated the door alarm was sounding. The OT stated she attempted to turn off the alarm but was unsuccessful. Further interview with the OT revealed she did not question why the alarm was sounding. She stated when the Assistant Director of Nursing (ADON) arrived and silenced the alarm, she left the unit with Resident #7. Continued interview revealed she did not hear a Code 99 announced, and she did not observe any staff counting residents. Additionally, the OT stated she knew about the facility's policy to look for any residents outside of the facility and that they were to do a head count of all the residents after a door alarm sounded. Review of the Daily Activity Schedule (OT), dated 05/04/2022, revealed the OT worked with Resident #7 between 9:48 AM and 10:19 AM. Interview with the ADON, on 05/25/2022 at 11:40 AM, revealed she was assisting with Resident #8 about 10:00 AM on 05/04/2022. She stated she went to the HSC Unit to assist, and when she arrived on the unit, the HSC Short Hall exit door alarm was sounding. She stated she reset the alarm. Further interview revealed a code was not announced over the pager system and a head count was not performed. She stated a Code 99 should have been announced and a head count of residents initiated at that time, per the facility's policy of an unknown trigger of a door alarm. Interview with Registered Nurse (RN) #1, on 05/25/2022 at 2:23 PM, revealed she arrived on the HSC Unit about 10:15 AM on 05/04/2022. She stated when she arrived, there were no alarms sounding. In addition, she stated, at approximately 11:00 AM on 05/04/2022, the DOM and the DON returned Resident #1 to the unit. She stated she assessed Resident #1, and the resident was not physically or mentally harmed. RN #1 stated the DON then escorted Resident #1 off the unit. Interview with RN #2, on 05/25/2022 at 3:45 PM, who was caring for Resident #1 on 05/04/2022, revealed she was assisting Resident #8 during the time of the elopement. RN #2 stated she did not hear an alarm sounding, nor did she hear a code announced. In addition, she stated she last saw Resident #1 in the dining room that morning; but, she did not recall the time. She stated she was informed about Resident #1's elopement by the ADON. Interview with State Registered Nurse Aide (SRNA) #5, on 05/26/2022 at 8:07 AM, revealed she was a caregiver for Resident #1 on 05/04/2022. She stated she last saw Resident #1 about 9:30 AM on 05/04/2022. Per the interview, she stated she was assisting RN #2 with Resident #8 during the time of the elopement. She stated she did not hear a Code 99 announced, and an accounting of all the residents was not performed. Interview with the Director of Nursing (DON), on 05/26/2022 at 10:18 AM, revealed the DOM called her and requested she meet him at his vehicle. She stated, when she arrived, Resident #1 was sitting in the front seat on the passenger's side of his vehicle. She stated the resident was calm, clean, and dressed in street clothes. She stated she then took the resident to RN #1 for a complete assessment. The DON stated, after the resident was assessed, she monitored the resident until one-to-one (1:1) observation could be implemented. Interview with the Administrator, on 05/26/2022 at 10:43 AM, revealed a head count of the residents should have been conducted, but it was not done. Further interview revealed a Code 99 was not announced over the public address system, and a code should have been announced. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 06/06/2022 that alleged removal of the IJ, on 05/19/2022, and that substantial compliance was achieved on 05/21/2022. Review of the IJ Removal Plan revealed the facility implemented the following: 1. Resident #1 was put on one-to-one (1:1) supervision immediately on 05/04/2022 and downgraded to fifteen (15) minute checks following an Interdisciplinary Team (IDT) review at 7:00 PM on 05/04/2022. The resident remained on every fifteen (15) minute checks for the next three (3) weeks and was decreased to thirty (30) minute checks following an IDT review on 05/24/2022. Resident #1's comprehensive plan of care was updated throughout this process. The IDT consisted of at least three (3) of the following team members: Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Activities Director, Dietary Director, Director of Therapy, Director of Maintenance (DOM), Business Office Director, Human Resources Director, Social Services Director, Admissions Director, Licensed Nursing staff, and Certified Nursing staff. 2. A head-to-toe assessment was completed on Resident #1 on 05/04/2022 by a unit nurse. No issues were noted. 3. An investigation was initiated and an incident report was completed by the Unit Nurse on 05/04/2022, and a self-reportable incident was completed and submitted to the Office of Inspector General (OIG/State Survey Agency) and Adult Protective Services (APS) by the DON and the NHA on 05/04/2022. During the investigation, interviews were conducted, on 05/04/2022 by the DON, and witness statements were obtained from all witnesses. 4. A facility wide maintenance check was completed by the DOM to ensure Wander Guards and doors were functioning appropriately on 05/04/2022. All Wander Guards and doors were functioning appropriately. In addition, the facility created and implemented daily audits log for all exit doors on 05/05/2022. 5. On 05/04/2022, all exit doors were locked down by the DOM. These exit doors were not to be used as entrance and exit except for fire exit release during an emergency. All staff and visitors must go in and out of the main entrance. The main entrance was keypad locked and had a door screener present from 7:00 AM to 7:00 PM. In addition, all exit doors had DO NOT EXIT signs posted on them on 05/04/2022 by the DOM. 6. One-to-one (1:1) supervision in-servicing, and following policies and procedures education was conducted by the Regional Nurse Consultant (RNC) for the ADON on 05/04/2022. Also, one-to-one (1:1) supervision in-servicing, and following policies and procedures education was conducted by the Director of Therapy for the OT on 05/04/2022. 7. The facility created and started an all-staff in-service to review the elopement policy, and specifically, what to do when an alarm sounded in the facility. Each participant was required to pass a post-test to ensure competency. Education was initiated on 05/04/2022, and one-hundred percent (100%) of staff was educated by 05/13/2022. Any new staff members, agency staff, or staff on leave were required to have education prior to starting their shift. This education would be completed by the Human Resource Director, the Administrator, or Licensed Nursing Management Designee. 8. The Quality Assurance and Performance Improvement (QAPI) Committee met to discuss a plan for education of staff and systemic changes put in place on 05/05/2022 and approved them. Education, elopement drills, and new audits were reviewed. The QAPI Committee included the DON, the Medical Director, the Assistant Director of Nursing (ADON), the NHA, the Social Services Director, and the Activities Director. 9. Elopement books were updated, pictures of all elopement residents were enlarged, and an elopement book was added at the main entrance on 05/05/2022. This was completed by the Administrator and Social Services Director (SSD). Also, audits in place for Elopement Binders were to be checked by the SSD. Audits were to be done weekly for twelve (12) weeks. 10. The facility implemented elopement drills conducted by the DOM, which continued every shift for two (2) weeks to ensure all staff would be involved in more than one (1) elopement drill. These drills were completed from 05/05/2022 to 05/18/2022. 11. The RNC met with Care Plan team members (MDS Coordinator, DON, ADON, SSD, and Activities Director), on 05/06/2022, to educate on the importance of personalized care plans and that they must be individualized to meet each resident's needs. 12. On 05/12/2022, the equipment for fourteen (14) of fourteen (14) residents identified as At risk for elopement had their Wander Guard equipment checked by administrative nursing staff to make sure the equipment was in place and functioning appropriately. No concerns were identified. 13. The IDT met, on 05/12/2022, and reviewed fourteen (14) residents' clinical records, that were assessed as At risk for elopement, to update their CCP, Physician's Orders, and individualized activities for each resident. The IDT included the ADON, MDS Coordinator, SSD, and Activities Director. The IDT conducted the reviews to ensure the Physician's Orders included a Wander Guard, with placement, function checks, and necessary supervision. Each resident's care plan was revised to include individualized activities and supervision to meet their individual needs regarding their risk for elopement. 14. On 05/13/2022, the QAPI Committee met and reviewed that one-hundred percent (100%) of education was completed for staff. New staff, agency staff, and any staff on leave would be educated by HR/Nurse Management Designee prior to start of their work shift. Elopement drills had been completed to date and would continue to 05/18/2022 to complete two (2) weeks of drills on each unit. 15. Black floor mats were ordered and placed next to each door, on 05/17/2022, as a deterrent for residents to exit. 16. On 05/20/2022, the QAPI Committee met to review and approve the IJ Removal Plan. The Committee also determined the facility would allege they had achieved substantial compliance as of 05/21/2022. The QAPI Committee found that audits of At risk for elopement residents were in place, elopement binders were updated and being audited weekly, all elopement drills were completed daily, each shift for two (2) weeks and would continue once a week for the next four (4) weeks. The Medical Director approved the actions taken. In addition, the QAPI Committee will meet weekly to discuss audits in place, education outcomes, and any issues that arise for the next twelve (12) weeks. The State Survey Agency validated the implementation of the facility's IJ Removal Plan and substantial compliance as follows: 1. Resident #1 was put on one-to-one (1:1) supervision immediately on 05/04/2022 and downgraded to fifteen (15) minute checks following an IDT review at 7:00 PM on 05/04/2022. The resident remained on every fifteen (15) minutes checks for the next three (3) weeks and was decreased to thirty (30) minute checks following an IDT review on 05/24/2022. The IDT included the Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Activities Director (DOA), Dietary Director (DM), Therapist Director (RM), Director of Maintenance (DOM), Business Office Manager (BOM), Human Resources Director (HR), Social Service Director (SSD), Admissions Director (AD), and Licensed and Certified Nursing staff. Review of Resident #1's medical record revealed his/her Comprehensive Care Plan (CCP) was updated throughout this process. Review of the facility's investigation into the 05/04/2022 elopement incident revealed on 05/04/2022, Resident #1 was put on one-to-one (1:1) supervision. Review of Resident #1's CCP revealed fifteen (15) minute checks were initiated following the incident. Review of Resident #1's medical record revealed an Incident Note, on 05/04/2022 at 7:00 PM (late entry) that stated the resident was on one-to-one (1:1) supervision. Record review revealed, following an IDT review, on 05/04/2022 at 7:00 PM, Resident #1 was downgraded to every fifteen (15) minute checks for three (3) weeks. Following an IDT review on 05/24/2022, Resident #1's supervision was downgraded to every thirty (30) minute checks. On 05/28/2022, every fifteen (15) minute checks were initiated. Resident #1's CCP was updated throughout the process to reflect changes in supervision. Continued review of the Quality Assurance and Performance Improvement (QAPI) Committee meeting documentation revealed Resident #1's CCP was reviewed and updated, on 05/04/2022, by the DON, ADON, and the Minimum Data Set (MDS) Coordinator. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed Resident #1 was placed on one-to-one (1:1) supervision immediately after the incident. Per the DON, one-to-one (1:1) supervision meant that a staff member had eyes on the resident at all times. Resident #1 remained on one-to-one (1:1) supervision for the remainder of the 7:00 AM to 7:00 PM shift on 05/04/2022. The DON stated the IDT met and reviewed Resident #1's behavior assessment and recommended to downgrade Resident #1's supervision to every fifteen (15) minute checks. She stated Resident #1 remained on every fifteen (15) minute supervision until 05/24/2022, when the IDT recommended to downgrade Resident #1's supervision to once every thirty (30) minutes. The DON stated, on the recommendation of the Regional Nurse Consultant (RNC), on 05/28/2022, all residents assessed as At risk for elopement were placed on every fifteen (15) minute checks. Further interview revealed Resident #1's CCP was updated by the DON, ADON, and the MDS Coordinator throughout the process to reflect changes in supervision. Interview with the RNC, on 06/07/2022 at 4:47 PM, revealed on 05/04/2022 Resident #1 eloped. The RNC stated the DON assessed Resident #1 and initiated one-to-one (1:1) supervision of the resident. According to the RNC, Resident #1 was on one-to-one (1:1) supervision for the remainder of the shift, at which time the IDT reviewed Resident #1's assessment and placed him/her on every fifteen (15) minute checks. The RNC stated on 05/28/2022, after review of the Comprehensive Care Plans, for residents assessed as At risk for elopement, she recommended these residents be placed on every fifteen (15) minute checks. Interview with Patient Care Assistant (PCA) #1, on 06/07/2022 at 11:26 AM, revealed that she and other designated staff monitored residents At risk for elopement as ordered on both the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shifts. She stated all resident checks were documented on the twenty-four (24) hour sheets, which were kept in a binder and scanned into the resident's chart. 2. Review of Resident #1's medical record revealed a head-to-toe assessment was performed, on 05/04/2022 at 10:45 AM, by Registered Nurse (RN) #1. No injuries were noted. Interview with RN #1, on 06/06/2022 at 2:23 PM, revealed she performed a head-to-toe assessment on Resident #1 immediately following the elopement incident on 05/04/2022. RN #1 stated there were no injuries or symptoms of distress. 3. Review of the facility's investigation of the 05/04/2022 elopement incident revealed the incident report was completed by RN #2. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed that she and the NHA completed and submitted a self-reportable incident report to OIG (Office of Inspector General/State Survey Agency) on 05/04/2022. Further review revealed the DON conducted interviews, and witness statements were obtained from Licensed Practical Nurse (LPN) #2, DOM, ADON, RM, and Occupational Therapy (OT). 4. Review of the facility's investigation into the 05/04/2022 elopement incident revealed that a facility-wide maintenance check was completed by the DOM to ensure Wander Guards and exit doors were functioning appropriately on 05/04/2022. Review of the Daily Alarm Check Log sheets, from 05/04/2022 to 06/07/2022, for all twelve (12) exit doors, revealed an inspection was conducted and the system passed. Interview with the DOM, on 06/06/2022 at 2:43 PM, revealed that all doors and Wander Guards were functioning appropriately. He stated that he did a daily inspection of all door alarms and functionality of the residents' Wander Guard alarm systems. The DOM stated there were twelve (12) exit doors, and each inspection included checking the magnetic locks, the wandering resident alarm systems, the door station alarms, and the remote alarm monitors. He stated the inspections, which began on 05/04/2022, were documented on the Daily Alarm Check Log sheets. He stated each of the twelve (12) outside exit doors were alarmed, and staff must input a code onto the keypad to disarm the alarm. Interview with the DON, on 06/07/2022 at 4:47 PM, revealed facility wide maintenance checks consisted of using a Wander Guard to set off the alarm. She stated each inspection was performed by the DOM and included checking the magnetic locks, wandering resident alarm systems, door station alarms, and the remote alarm monitors. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed the DOM daily audited the Wander Guard system to ensure all doors and Wander Guards were functioning appropriately. The NHA stated each inspection of the exit doors included checking the magnetic locks, the alarm systems, door station alarms, and the remote alarm monitors. Telephone interview with the Medical Director, on 06/07/2022 at 4:33 PM, revealed the facility audited the operation of the exit door alarms daily. 5. Observation of the main entrance revealed the screener sat at the main entrance door, on 06/06/2022 at 11:30 AM, and at multiple observations, on 06/06/2022 and 06/07/2022. The screener was observed screening all persons who entered the facility for COVID-19 and observing all persons that exited the facility. Observation of the facility's twelve (12) exit doors with the DOM, on 06/06/2022 at 10:15 AM, revealed all twelve (12) doors had been locked and a Do Not Exit sign was posted at each door. The doors could be opened for a fire exit in the event of an emergency. Continued observation revealed all doors were locked from the outside, and a code was needed to exit. Also, the alarm sounded when the bar was pushed if the code was not pressed. Interview with the DOM, on 06/06/2022 at 2:43 PM, revealed he locked down all exit doors, and a Do Not Exit sign was posted at each door. He stated these exit doors were not to be used as entrance and exit except for fire exit release during an emergency. The DOM stated there were twelve (12) exit doors. He stated all staff and visitors must go in and out of the main entrance. The DOM stated the main entrance was keypad locked and had a door screener present from 7:00 AM to 7:00 PM. Interview with the Screener, on 06/07/2022 at 9:44 AM, revealed the main entrance was monitored seven (7) days a week from 7:00 AM to 7:00 PM. The Screener stated the Activities Department covered for the Screener for breaks. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed all exit doors were locked down by the DOM and had a Do Not Exit sign placed. The NHA stated the exit doors were not to be used as entrance and exit except for fire exit release during an emergency. Continued interview revealed all staff and visitors must go in and out of the main entrance door, which was keypad locked and had a door screener present from 7:00 AM to 7:00 PM. She stated staff had been educated to use the main entrance for entering and exit. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed during the hours of 7:00 PM to 7:00 AM, the nurse on duty answered the main entrance bell. She stated the nurse must go to the door to let the visitor or staff into the building. 6. Interview with the RM, on 06/07/2022 at 2:45 PM, and the ADON, on 06/07/2022 at 3:27 PM, revealed, on 05/04/2022, both received one-to-one (1:1) supervision education provided by the RNC. Both stated the RNC also educated them on following the facility's elopement policies and procedures. Interview with the RNC, on 06/07/2022 at 4:49 PM, revealed it was determined that the root cause analysis (RCA) of the elopement revealed staff failed to follow the facility's policy and procedure on elopement. The RNC stated, based on the findings of the RCA, the RM and the ADON were given one-to-one (1:1) supervision education on the facility's elopement policies and procedures, which highlighted the importance of following elopement protocols to ensure the residents' overall well-being and safety. 7. Review of the Elopement Education sign-in sheets, dated 05/04/2022, revealed eighty-nine (89) staff were in-serviced on policy and procedure for elopement. Specific education focused on what to do when an alarm sounded in the facility and doing a head count of all residents. Review of the in-service attendance sheet, dated 05/13/2022, revealed the DON and ADON attended a teleconference in-service, facilitated by the RNC, which focused on the facility's elopement protocol. The sheet was reviewed by the NHA. Interview with MDS Assessment Nurse, on 06/06/2022 at 4:30 PM, revealed she had participated in elopement training. She stated a pre and posttest focusing on elopement protocols was given, and she passed the test. Interview with the AD, on 06/06/2022 at 4:37 PM, revealed she was involved in creating an in-service to educate all staff regarding the facility's elopement policy and procedures. Per the interview, the AD participated in an in-service, on 05/04/2022, which focused on the facility's elopement protocol and what to do when an alarm sounded in the facility. She stated a pre and posttest focusing on elopement protocols was given, and she passed the test. Interview with Dietary Aide (DA) #1, on 06/06/2022 at 4:57 PM; the Screener, on 06/07/2022 at 9:44 AM; Dietary Aide (DA) #3, on 06/07/2022 at 10:36 AM; the Dietary Manager, on 06/07/2022 at 10:46 AM; PCA #1, on 06/07/2022 at 11:02 AM; SRNA #7, on 06/07/2022 at 11:31 AM; DA #4, on 06/07/2022 at 12:01 PM; DA #5, on 06/07/2022 at 12:10 PM; SRNA #13, on 06/07/2022 at 1:40 PM; SRNA #5, on 06/07/2022 at 1:47 PM; SRNA #9, on 06/07/2022 at 1:52 PM; Housekeepers #2, #3, #4, and #5, on 06/07/2022 at 1:58 PM; OT, PT, and Speech Therapy (ST), on 06/07/2022 at 2:08 PM; SRNA #10, #11, and #12, on 06/07/2022 at 2:23 PM; the SSD, on 06/07/2022 at 1:53 PM; and the HSC DOA, on 06/07/2022 at 3:11 PM revealed all had been educated on elopement protocols, to use the main entrance only, and elopement drill procedures. All stated they had taken a posttest and passed. Interview with the ADON, on 06/07/2022 at 3:27 PM, revealed she participated in a facility-wide elopement in-service on 05/04/2022 and 05/13/2022, which educated staff on the steps to take if an elopement occurred. She stated the education stressed not assuming the resident by the door was the one who set off the alarm and doing a resident head count. The ADON stated she educated staff on the policies and procedures for elopement. Furthermore, she assisted with educating staff who were absent on the days of the regular educational in-service. She stated all new staff and agency staff were required to have education prior to working his/her shift. She stated new staff would go through an elopement drill in orientation with the DOM. The ADON stated agency staff received a packet with all elopement protocols when they started. She stated the nursing manager was responsible to ensure agency staff completed the elopement education. She stated that staff education began on 05/04/2022, and one-hundred percent (100%) of the staff were educated by 05/13/2022. Interview with the DON, on 06/07/2022 at 4:27 PM, revealed she facilitated a facility-wide elopement in-service, which educated staff on the steps to take if an elopement occurred. She stated that staff education began on 05/04/2022, and one-hundred percent (100%) of the staff were educated by 05/13/2022. The DON stated the education stressed not assuming the resident by the door was the one who set off the alarm and doing a resident head count. She stated all staff took a pre-training test and were required to pass a posttest focusing on elopement protocols. Interview with the RNC, on 06/07/2022 at 4:49 PM, revealed she in-serviced the DON and the ADON on 05/13/2022 related to elopement protocols. She stated that staff were taught not to assume that the resident near the exit wearing a Wander Guard was the one who set off an alarm. She stated she stressed that a head count of all residents must be completed during an elopement. Interview with the NHA, on 06/07/2022 at 4:18 PM, revealed she was involved in the review of the facility's elopement policy and procedures and the process for educating all staff. Per the interview, the NHA stated all new staff received education on the facility's elopement policy in orientation. She stated all new staff and agency staff were required to have education prior to working his/her shift. Per the NHA, new staff also went through an elopement drill in orientation with the DOM. She stated the ADON was to ensure agency staff received a packet with all elopement protocols when they started; then agency staff would be educated by the Staff Development Coordinator (SDC) and the ADON. She stated that staff education began on 05/04/2022, and one-hundred percent (100%) of staff were educated by 05/13/2022. Telephone interview with the Medical Director, on 06/07/2022 at 4:33 PM, revealed the facility facilitated the education of staff about the Elopement Policy through in-service education and elopement drills. 8. Review of the 05/05/2022 QAPI Committee meeting agenda and sign-in sheet revealed the QAPI Committee m [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the person-centered comprehensive care plan for one (1) of fourteen (14) sampled residents (Resident #15). Staff interviews and record review revealed Resident #15 required one (1) staff assist for transfers and toileting; had frequent falls; and, attempted to toilet self without assistance. Review of Resident #15's incident reports, dated 02/18/2020 through 06/02/2021, revealed he/she had a total of sixteen (16) falls at the facility. Continued review revealed at least eleven (11) of the sixteen (16) falls occurred while the resident was attempting to toilet himself/herself. However, the facility failed to identify that the resident had repeated falls while attempting to toilet. The failed to revise the resident's care plan to prevent further falls. On 03/31/2021, Resident #15 experienced three (3) falls. Two (2) of the three falls occurred when the resident was attempting to toilet himself/herself. The resident sustained injuries from the fall(s) and was diagnosed , on 04/05/2021, to have a comminuted fracture of the proximal tibial shaft with displacement of fracture fragments, a comminuted fracture of proximal fibula, and a transverse minimally distracted fracture of the patella. On 06/02/2021, Resident #15 experienced a fall while in the bathroom. The resident was sent to the hospital and diagnosed with an acute non-displaced tibial fracture with other healing chronic tibia and fibula fracture. The facility's failure to ensure residents' care plans were revised to prevent further falls has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/12/2021, and determined to exist on 03/18/2020 at 42 CFR 483.21 Comprehensive Resident Center Care Plan, F657. The facility was notified of the Immediate Jeopardy on 10/12/2021. An acceptable Allegation of Compliance was received on 10/21/2021, which alleged removal of Immediate Jeopardy on 10/22/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 10/22/2021 as alleged, prior to exit on 10/28/2021, with remaining non-compliance in the area of 483.21 Comprehensive Resident Centered Care Plan, F657, at a scope and severity of a E, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes . Findings include: Review of facility policy titled, Baseline Care Plan Assessment/Comprehensive Care plans, (undated) revealed the Comprehensive Care Plan would further expand on resident risks, goals and interventions using the Person-Centered Plan of Care approach for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. Further review revealed the Minimum Data Set (MDS)/Care Plan Coordinator and/or ancillary MDS staff would attend morning meetings where in depth review of 24 hour report are reviewed and discussed as well as new or changed orders, new admissions, readmissions, falls, and other pertinent circumstances regarding the residents. They would then see that the care plans for the residents were revised and updated as necessary. Review of facility policy titled, Incidents/Accidents/Falls, undated, revealed the facility will ensure that accidents and incidents that occur involving residents are identified, reported, investigated and resolved. Further review revealed all falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall to help provide information to enable staff to roll out interventions to prevent another similar occurrence, noting each fall needs a new intervention rolled out. Continued review revealed some occurrences will require a more extensive investigation process that includes, falls with significant injury and any fracture. Review of Resident #15's clinical record, revealed the facility admitted the resident, on 04/16/2015, with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Polyosteoarthritis and Alzheimer's Dementia. Review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #15 required one (1) person staff assist for all transfers, toileting, and to ambulate in room and/or on the unit. Review of Resident #15's Comprehensive Care plan, dated 12/05/2017, revealed a focus area for serious injury related to falls with a goal to remain from future serious injury from falls. Further review revealed interventions to include: bed in lowest position for safe transfers; call light in reach when in bed; keep room clean, neat and clutter free, and lighting at the resident's preference. Continued of Resident #15's Comprehensive Care Plan, revealed interventions, dated 11/11/2019, to keep a fall mat to the exit side of the bed and interventions dated 12/06/2019 to cue the resident to use the call light for safety needs. Interventions added on 06/02/2021 were to add bright colored tape to the call bell, to keep frequently used personal items at bedside, night light in room, and assist of one (1) person for bed mobility, toileting and transfers. Additionally, a sign was posted to remind the resident to use his/her call bell for assist. Further review revealed interventions add on 06/24/2021, for a foam pommel cushion, anti-rollbacks, left leg rest, anti-tipper to rear of wheelchair and dysom under cushion to wheelchair. Review of incident report for Resident #15 dated 07/09/2020 revealed he/she fell in the bathroom attempting to toilet unassisted. Further review revealed no documented evidence the resident's care plan was revised with new interventions. Additionally, there was no root cause of the resident's fall was identified, and the resident's current interventions were continued. Review of Resident #15 incident report dated 10/20/2020 revealed the resident fell while trying to toilet unassisted in a urinal and received a laceration to the left earlobe as a result of the fall. Further review revealed no root cause was identified, no new interventions were was implemented, and his/her current interventions were continued. Review of Resident #15's incident reports, dated 01/18/2021 and 02/02/2021, revealed the resident fell while attempting to transfer from his/her wheelchair to his/her bed unassisted on 01/18/2021. Further review revealed the resident fell while attempting to transfer from wheelchair to toilet on 02/02/2021. Further review revealed no root cause was identified for the falls, and each fall had an intervention to remind resident to use his/her call light for assistance before transferring. Further review of the facility's falls incident reports revealed Resident #15 experienced eight (8) falls while going to the bathroom and/or attempting to toilet between 02/18/2020 and 03/27/2021. However, the facility failed to implement interventions addressing the resident's attempts to toilet independently and failed to revise the resident's care plan to include interventions to prevent further falls. Review of the facility's falls incident report dated 03/27/2021 at 7:58 PM revealed Resident #15 experienced a fall while toileting and sustained a purplish abrasion to the left buttock and blood was noted under the resident's nails to the third (3rd) and fourth (4th) digit of his/her right hand. The facility reviewed the resident's care plan and added an intervention to educate resident to make sure the back of his/her legs were touching the wheelchair before sitting down. However, the facility failed to revise the care plan to address the resident's attempt to toilet himself/herself unassisted. Interview with Licensed Practical Nurse (LPN) #12, on 10/05/2021 at 8:40 PM, revealed she provided care to Resident #15 on 03/27/2021 from 7:00 PM to 7:00 AM and was working when Resident #15 fell . She stated the resident had to be frequently reminded to use his/her call bell. She further stated she did not recall the resident ever having a toileting program, but the resident had periods of incontinence prior to fracturing his/her leg and was now more incontinent since the injury and required a Hoyer lift. Per the LPN, the nurse documents a description of the incident/fall on the incident report and in the nursing notes. Further, she stated the Director of Nursing (DON) would be notified, and an intervention/revision to the resident's care plan would be put in place. Review of incident report dated 03/31/2021 at 3:30 AM revealed Resident #15 had an unwitnessed fall while attempting to use a urinal. Further review revealed no root cause of the fall was identified through investigation, no intervention was noted, and resident was attempting to toilet unassisted. Review of incident report dated 03/31/2021 revealed Resident #15 had a second unwitnessed fall at approximately 3:40 AM, ten (10) minutes after the initial fall. Staff noted injuries of bruising to the left side of neck, bruising to left hip, and swelling of left lower leg. Per review, interventions were put in place to place grip strips under the resident's fall mat and to send the resident to the emergency room (ER). However, further review revealed no root cause was identified through the facility's investigation or the resident was attempting to toilet unassisted. Review of the hospital emergency room (ER), record dated 03/31/2021, revealed Resident #15 arrived to hospital at 5:09 AM and was evaluated for left hip and leg pain and had negative x-rays of bilateral hip and pelvis with swelling noted to left leg shin. Resident was discharged from hospital at 8:30 AM back to the facility with no significant injuries noted. Review of incident report dated 03/31/2021 at 2:50 PM revealed Resident #15 had a third unwitnessed fall after returning from the ER. Per the incident report the resident fell while in the bathroom attempting to use the bathroom. The resident was assessed with no new injuries and an intervention placed for therapy to evaluate increased weakness in bilateral extremities. Further review revealed again the facility failed to identify/address the resident was attempting to toilet unassisted. Interview with State Registered Nurse Aide (SRNA) #12, on 10/04/2021 at 9:34 PM, revealed she was working on 03/31/2021 and provided care to Resident #15 from 7:00 PM to 7:00 AM during night shift. She stated the resident had a history of being non-compliant with ringing call bell for assistance and he/she had frequent falls attempting to ambulate unassisted to bathroom. However, she stated she did not recall Resident #15 having increased monitoring or a toileting program in place at the time of the falls. Interview with Licensed Practical Nurse (LPN) #5, on 10/04/2021 at 3:50 PM, revealed she provided care to Resident #15 from 7:00 AM-7:00 PM during day shift on 03/31/2021. She stated the resident would frequently attempt to toilet himself/herself unassisted and required a staff assist of one (1) at the time of the falls. She further stated Resident #15 was not on a toileting program or increased supervision. Further, the LPN stated revising the resident's care plan to include interventions related to toileting the resident every hour and providing increased supervision would have been helpful for the safety of the resident. Review of the facility's falls incident report, dated 06/02/2021 at 11:15 AM, revealed Resident #15 was heard yelling for help and upon entering the resident's room, resident was noted to be laying on the bathroom floor. Upon assessment, resident's left leg was noted to be twisted one-hundred and eighty (180) degrees behind him/her with his/her foot pointing backwards. Resident #15 told staff he/she was attempting to transfer self to the toilet at the time of the fall. Resident #15 was sent to the ER via ambulance for further evaluation. Further review revealed no documented evidence the resident's care plan was revised to address the residents attempts to toilet unassisted. Interview with Minimum Data Set (MDS) Assessment Nurse, on 10/06/2021 at 11:25 AM, revealed she was responsible for revising/updating the resident's care plans daily. Per the MDS nurse, the unit nurse updated the care plan after a resident fall and the interdisciplinary team (IDT) would discuss the fall in the morning meetings. The MDS Nurse stated the IDT would review the intervention initially initiated by the unit nurse and revise the interventions if needed. She stated if changes were made on a weekend by the unit nurse, related to new orders, or a fall, it would be discussed in the Monday morning meeting and the care plan would be reviewed/revised. The MDS Assessment Nurse further stated if new interventions were added during the day, the nursing staff would call her immediately so the care plan could be revised and updated with the new intervention. Per the MDS Assessment Nurse, the previous, current, and new care plan interventions were reviewed/discussed in the morning meetings. Interview with Medical Director, on 10/07/2021 at 2:40 PM, revealed he was not aware Resident #15 had sixteen (16) falls since 02/18/2020. He stated he expected the facility to provide a safe environment for residents, thoroughly investigate falls, and put interventions in place to prevent falls to protect the residents from injury. Interview with Director of Nursing (DON), on 10/06/2021 at 1:50 PM, revealed when a fall incident occurred, an investigation would be done at the time of the incident and discussed with her to ensure appropriate interventions were put into place for the resident. The DON stated she was aware Resident #15 had several falls while attempting to toilet. The DON stated the resident was independent and non-complaint with interventions. Continued interview with DON, on 10/06/2021 at 5:08 PM, revealed she tracked and trended falls and the facility looked at what occurred, what the resident was doing at the time of the fall, and the care plan was reviewed and/or revised with new interventions. She further stated falls were discussed in morning clinical meetings and the MDS Assessment Nurse guides care planning and interventions. Further, the DON stated the facility failed to identify Resident #15's recurrent falls. Additionally, the DON stated if a resident continued to have recurrent falls, continuing the same interventions was not effective in preventing further falls. The DON stated Resident #15 wanted to be independent and she believed this was the reason the resident was non-compliant with the fall care plan interventions. Interview with Administrator, on 10/06/2021 at 5:55 PM, revealed after a fall occurred, the facility investigated the incident and an intervention would be put into place. He further stated falls were then reviewed in clinical morning meetings held Monday through Friday. The Administrator stated staff were expected to review and revise resident care plans after each fall. Per the Administrator, he attends the monthly Quality Assurance and Performance Improvement (QAPI) Meetings where resident falls are reviewed. However, the Administrator stated he was not aware Resident #15 had experienced 16 falls. **The facility implemented the following actions to remove the Immediate Jeopardy on 10/22/2021: 1. Resident #15 and Resident #16 were placed on every fifteen (15) minute checks, on 10/12/2021, while an interdisciplinary team (IDT) review occurred. On 10/13/2021 the Unit Manager (UM)/Registered Nurse (RN) #1 completed a physical assessment of both resident's and no injuries were identified. 2. On 10/15/2021 at 8:14 PM, the Director of Nursing (DON) documented an IDT meeting was conducted and the following people were in the meeting: The DON, Assistant Director of Nursing (ADON), the UM/RN #1, Director of Maintenance , Activities Director, Social Services Director, Physical Therapy Assistant, State Registered Nurse Aide (SRNA) #3 and the Minimum Data Set (MDS) nurse. The IDT completed a review of Resident #15 and Resident #16 related to fall risk, level of necessary supervision, use of assistive devices (including side rails). The IDT also conducted a root cause analysis of Resident #15's fall which occurred on 06/02/2021 and Resident #16's fall which occurred on 08/28/2021. Further, the interdisciplinary team (IDT) reviewed the residents' current fall interventions and determined the every fifteen (15) minute checks were continued. Resident #15 and Resident #16's care plans and nurse aide Kardex were revised by the Minimum Data Set (MDS) nurse during the review. 3. The facility conducted audits from 10/13/2021 to 10/16/2021, which identified residents at risk for falls with potential to be affected by inaccurate fall investigations and identification of root cause analysis. Residents identified as at risk were reviewed by the IDT and the residents' care plans were reviewed, for fall risk, level of necessary supervision, use of assistive devices, and current interventions. The facility audited twenty-one (21) residents with orders for low air loss mattresses. Further, the facility audits determined, sixteen (16) mattresses were discontinued. The audits also identified five (5) residents benefited from the continued use of air mattresses and the risk verses benefit of using a low air loss mattress was discussed with the resident's and/or their responsible parties. Consents were obtained for the continued use of the devices for those five (5) residents. 4. On 10/15/2021, Registered Nurse (RN) #1 completed a side rail and a low air loss mattress assessment on Resident #16 to determine the risk verses benefit for both devices. During the review, the RN determined Resident #16 utilized his/her side rails as an enabler and he/she also benefited from the use of a low air loss mattress. The facility determined the resident's mattress type was changed to a Pressure-Guard low air loss mattress and settings were determined to be appropriate based on manufacturer's guidelines. On 10/15/2021, the risk, which included entrapment, versus the benefit of side rail use as well as the use of a low air loss mattress was reviewed by RN #1 with Resident #16 and his/her responsible party, and consent was obtained to utilize both devices. Further, Resident #16's alternating low air loss mattress was checked for accuracy of settings/function every shift and documented on the medication/treatment record by the nursing staff. Any concerns identified was immediately reported/addressed by nursing/maintenance. 5. The facility conducted audits and assessments on 10/15/2021 and 10/16/2021 by therapy, nursing and maintenance staff of all side rail utilized in the facility. Residents were screened by therapy and assessed for use per the manufacturer's guidelines to ensure residents' safety. Staff reviewed the side rails to determine the following; medical need for the side rail, accurate assessment completed, specific orders, proof of education regarding the risks/benefits of the side rails, consents for use of the side rails, ensure the care plan and nurse aide Kardex reflected the use of the devices, and proper fit and attachment of the side rails. Any resident identified to benefit for the continued use of side rails was evaluated by therapy staff to ensure appropriate use of the device. 6. On 10/18/2021, the IDT conducted a care plan meeting to complete a comprehensive review of Resident #15 and Resident #16's fall risk, level of necessary supervision, use of assistive devices as applicable, and the resident's current interventions to reduce falls, which included but was not limited to the following items: Brief Interview for Mental Status (BIMs) Score, vision, hearing, medications, labs, and pain. The IDT requested follow up laboratory tests for Resident #15 which included a Prostate Specific Antigen (PSA) and a diagnostic test for a Post Void Residual. The team also requested the resident's physician and psychiatric services review of Resident #15's medications. The IDT reviewed Resident #15's and Resident #16's record weekly during the Falls Meeting for a period of at least four (4) weeks to monitor the efficacy of the fall interventions and revised the interventions as needed. 7. Administrative and direct care staff were trained on the regulatory requirements for F689 and F700 which included definition of an accident, environmental hazards, fall analysis, revision of care plans, root cause analysis, appropriate interventions, resident supervision, fall meetings, side rails and low air loss mattress assessments/consents, risk versus benefits, appropriate alternatives, general safety tips for use of mattresses and appropriate settings and the manufacturer's guidelines for air mattresses utilized in the facility. Further, the training also included licensed staff to monitor and document every shift on the treatment record to indicate air mattresses were on the proper settings. Staff knowledge of training conducted was measured by post-test which required a score of one-hundred (100%) percent. All staff that were not trained by 10/21/2021 were required to complete training and post-tests prior to working next scheduled shift. 8. On 10/20/2021, a Side Rail, Fall Prevention/Resident Supervision, Low Air Loss Mattress Quality Review Audit tool was reviewed/accepted by the Quality Assurance Performance Improvement (QAPI) Committee. The audit tools would be completed five (5) times a week for twelve (12) weeks and results of the audits would be discussed in the monthly QAPI meetings. After the initial twelve (12) week review, a minimum of ten (10) residents would be reviewed monthly for falls. Following the initial twelve (12) week audits conducted related to side rails/air mattresses, audits would continue to be conducted twice (2) monthly for all residents which utilized the devices in the facility. All audits would continue to occur until one-hundred (100%) percent compliance had been determined by the QAPI committee. Any identified concerns would be reported to the QAPI committee and corrective action plans would be developed as needed. A regional team member would also attend QAPI to provide oversight and assist in ensuring compliance, monthly for three (3) months. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 10/22/2021 as alleged: 1. Review of Resident #15 and Resident #16's medical record and interview with the Assistant Director of Nursing (DON), on 10/28/2021 at 1:40 PM and Registered Nurse (RN) #1/Unit Manager, on 10/28/2021 at 1:00 PM, revealed on 10/12/2021, Resident #15 and Resident #16 were placed on every fifteen (15) minute checks to increase supervision until the Interdisciplinary Team (IDT) review was completed. Further review and interview with RN #1, on 10/28/2021 at 1:00 PM, revealed she assessed Resident #15 and Resident #16, on 10/13/2021 and no injuries were identified. 2. Review of Resident #15 and Resident #16's medical record and interview with the ADON, on 10/28/2021 at 1:40 PM, and Registered Nurse (RN) #1, on 10/28/2021 at 1:00 PM, revealed on 10/15/2021 at 8:14 PM, an IDT meeting was conducted. Record reviews and continued interviews revealed the IDT team completed a review of Resident #15 related to his/her fall risk, level of necessary supervision, use of assistive devices, which included side rails, and the team also completed a root cause analysis of his/her fall which occurred on 06/02/2021. Further review of the resident's documentation indicated the IDT reviewed the resident's current interventions to reduce falls and the resident's fall related injuries. Documentation in the medical record also revealed the IDT review determined Resident #15 had not fallen in the last ninety (90) days, and staff were to continue every fifteen (15) minute checks during this review. Interview with the ADON, on 10/28/2021 at 8:21 PM, revealed on 10/15/21 the IDT completed a review of Resident #16's fall risk, level of necessary supervision, use of assistive devices which included side rails. Further interview and record review revealed a completed root cause analysis of the fall which occurred on 08/28/2021. Further review/interviews with the ADON and RN #1 confirmed the residents' current interventions to reduce the risk for falls were reviewed and the team determined every fifteen (15) minute checks were to be continued and the residents' care plans were reviewed/revised to indicate the required checks. 3. Review of the facility's audits and interviews with the Assistant Director of Nursing (ADON) at 1:40 PM and Registered Nurse (RN) #1 at 1:00 PM on 10/28/2021, revealed on 10/13/2021, the Director of Nursing (DON) identified residents who had experienced falls within the last thirty (30) days. Continued interviews with the ADON, on 10/28/2021 at 1:40 PM; and the RN #1 at 1:00 PM, revealed the Interdisciplinary Team (IDT) team reviewed the residents' records from 10/13/2021 to 10/21/2021, to ensure fall investigations had been completed appropriately, which included identification of root cause analysis; circumstances which surrounded the falls; falls had been properly tracked/trended and implementation of interventions and preventive measures related to the identified root cause analysis was completed. Further review of the facility's audits and interviews, on 10/28/2021 at 1:40 PM with the ADON; at 1:00 PM with Registered Nurse (RN) #1 (Unit Manager); and at 2:00 PM with the Minimum Data Set (MDS); revealed fall investigations were completed. All identified resident care plans were reviewed to ensure the residents' fall risk were properly care planned which included appropriate level of supervision, the use of assistive devices (side rails and low air loss mattresses), interventions to prevent falls. The residents' responsible party consents were obtained. Continued review of facility's audits and interview with the Assistant Director of Nursing (DON) at 1:40 PM on 10/28/2021, revealed on 10/13/2021, twenty-one (21) residents with orders for low air loss mattresses medical records were reviewed. Further review and interviews indicated the residents' records were reviewed between 10/13/2021 to 10/16/2021, related to risk verses benefit of using a low air loss mattress. Observations and record review conducted on 10/28/2021 at 1:40 PM confirmed sixteen (16) residents with low air loss mattresses were discontinued based on the review conducted by the Interdisciplinary Team. Further observations revealed five (5) residents remained on low air loss mattress and were identified as having a benefit from continued use of the low air loss mattress. Reviews also revealed Maintenance validated settings were appropriate for each resident based on manufacturer's guidelines, and therapy staff had also evaluated the residents for continued use of the device, on 10/16/2021. Review of the five (5) residents (Resident #15, Resident #16, Resident # 18, Resident #19, Resident #20 and Resident #21) records confirmed the residents and/or their responsible parties were contacted between 10/13/2021 to 10/16/2021 and risks versus benefits were discussed with the parties and consents were obtained. According to facility documentation, after completion of the assessments, two (2) of the five (5) residents (Resident #15 and Resident #18) had recommendations for rails to be removed. Continued review of the facility's audit tools revealed administrative staff were monitoring to ensure documentation of the mattress settings. Interview with the Maintenance Director, on 10/28/2021 at 11:15 AM, and review of facility's training materials and audit tools, revealed on 10/19/2021, he was trained by the Administrator regarding utilization of the weekly preventive maintenance/monitoring log regarding all low air loss mattresses, to validate that the device was utilized in accordance with manufacturer's guidelines. 4. Review of Resident #16's record and interview with Registered Nurse (RN) #1, on 10/28/2021 at 1:00 PM revealed on 10/15/2021, she completed a low air loss mattress assessment on Resident #16 to determine the risk verses benefit of the continued use of the low air loss mattress. Interview with RN #1, on 10/28/2021 at 1:00 PM, revealed she determined Resident #16 benefited from a low air loss mattress, and also changed his/her mattress type to a Pressure-Guard low air loss mattress and settings were determined to be appropriate based on the manufacturer's guidelines. According to the record and interview with RN #1 and the ADON, on 10/28/2021 at 1:40 PM, the facility reviewed, on 10/15/2021, the risk which included entrapment, versus the benefit of the low air loss mattress with Resident #16 and his/her responsible party and consent was obtained to continue use of the device. Further review of Resident #16's record revealed staff monitored the air mattress settings for accuracy/function every shift and initialed the checks were complete. Interview with RN #2, on 10/28/2021 on 1:20 PM, confirmed staff were to monitor Resident #16's air mattress settings every shift and if any concerns were identified, they would immediately notify nursing and/or maintenance. Review of Resident #16's record revealed on 10/15/2021, the RN #1, along with Physical Therapy staff and the Maintenance Director conducted a side rail assessment to determine the risk verses benefit of side rails, and determined the resident utilized the side rails, and would benefit from the continued use of the side rails. Review of the medical record for Resident #16 revealed on 10/15/2021 the risk which included entrapment, verses benefit of side rails was reviewed by RN #1 with Resident #16 and his/her responsible party and consent was obtained for the side rail to be utilized in the facility. 5. Review of facility documentation and interviews on 10/28/2021 at 1:40 PM with the ADON and at 1:00 PM with RN #1 revealed on 10/15/2021 to 10/16/2021, all residents utilizing side rails were assessed by nursing, therapy, and maintenance for continued use of side rails and residents and/or their responsible parties were contacted for residents that utilized side rails. Further review revealed the facility explained the risk versus benefit of side rails and consents were obtained to continue use of the device. 6. Review of Resident #15 and Resident #16's medical record and interviews with the Minimum Data Set (MDS) nurse, on 10/28/2021 at 2:00 PM, and interview with the Assistant Director of Nursing (ADON), on 10/28/2021 at 1:40 PM, revealed Resident #15 and Resident #16 had been reviewed weekly by the IDT team during the Falls Meetings and continued to be reviewed for four (4) weeks, to ensure effectiveness of current fall interventions and revised the residents' care plans and Kardex as needed. Observations on 10/27/2021 at 2:00 PM, revealed staff were in the residents' rooms and providing every fifteen (15) minute checks, as the residents, Residents #15 and #16, were roommates. Interviews with the ADON on 10/28/2021 at 1:40 PM; and the Minimum Data Set (MDS) nurse at 2:00 PM, revealed Resident #16's care plan and nurse aide Kardex was reviewed/revised to indicate staff were required to conduct the fifteen (15) minute checks as determined appropriate by the team. Interview with the State Registered Nurse Aide (SRNA) #13, on 10/27/2021 at 5:20 PM; and RN #4 at 10:30 PM, revealed every fifteen (15) minute checks continued for Resident #15 and Resident #16. Interview, on 10/28/2021 at 1:00 PM with Registered Nurse (RN) #1; and at 1:40 PM with the Assistant Director of Nursing (ADON) and review of Resident #15's medical record revealed, on 10/18/2021 at 6:33 PM [TRUNCATED]

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible and the residents received adequate supervision and assistive devices to prevent accidents for eight (8) of fourteen (14) sampled residents (Residents #15, #16, #7, #3, #10, #17, #5, and #6 ). In addition, the facility failed to ensure staff utilized a mechanical lift for three (3) residents (Residents #7, #5, and #6). 1. The facility assessed Resident #15 to require the assistance of one (1) staff for transfers and toileting. Resident #15 sustained sixteen (16) falls from 02/18/2020 to 06/02/2021. Review of the facility's fall documentation revealed eleven (11) of the sixteen (16) falls occurred when the resident was in the bathroom, coming out of the bathroom, or attempting to toilet. However, there was no documented evidence the facility conducted a comprehensive fall investigation in an attempt to identify circumstances surrounding the falls; tracked or trended data regarding the falls; or, attempted to determine the root cause of the falls. At approximately 3:30 AM on 03/31/2021, Resident #15 had an unwitnessed fall, rang his/her call light, and was observed by staff to be sitting on a mat beside the resident's bed and holding onto the bed rail. Resident #15 told staff he/she was trying to use the urinal and his/her feet got tangled. No injuries were noted. At approximately 3:40 AM on 03/31/2021, ten (10) minutes after the initial fall, Resident #15 had a second unwitnessed fall. Staff observed the resident sitting on the mat on the floor beside the bed with his/her head and back against the end table. Staff noted injuries of bruising to the left side of the resident's neck, bruising to the left hip, and swelling of the left lower leg. At 2:50 PM on 03/31/2021, staff heard Resident #15's emergency bathroom light sounding and found the resident lying on the floor in front of his/her toilet on his/her left side. Resident #15 told staff he/she was going to the bathroom but could not make it and fell . On 04/05/2021, the resident was diagnosed with an acute fracture of the Proximal Tibia (the upper part of the shinbone that connects to the knee joint) and Fibula (the segment between the knee and ankle) and Patella (the kneecap). The facility readmitted Resident #15 on 04/07/2021, with a long leg splint with a knee immobilizer. On 06/02/2021 at approximately 3:35 PM, facility staff heard Resident #15 yelling for help. Upon entering the resident's room, the resident was found lying on the bathroom floor with the left lower extremity turned one-hundred and eighty (180) degrees with his/her foot pointing backwards. The facility transferred the resident to the Emergency Department (ED), and the resident was diagnosed with an acute non-displaced Tibial fracture with other healing chronic Tibia and Fibula fractures. 2. Additionally, the facility failed to ensure an alternating pressure relief air mattress, utilized by Resident #16, was assessed for safety, set up to the appropriate settings, monitored, and operated in accordance with the Manufacturer's guidelines. On 08/28/2021, Resident #16 sustained a fall from his/her bed. Staff interviews and review of the facility's documentation determined the resident's right arm was entrapped in the bed rail and mattress and the lower part of the resident's body was on the floor. Staff were unable to free the resident's arm, until two (2) staff members removed the mattress from the bed frame. 3. The facility assessed Resident #7, on 03/05/2021, to require the use of a Hoyer lift (brand name of a mechanical lift) for transfers. On 07/23/2021, two (2) staff transferred Resident #7 without the use of a Hoyer lift. During the transfer, Resident #7 was lowered to the floor. The resident sustained a fracture to the left foot fifth (5th) digit and a hematoma (a collection of blood outside of the blood vessels) to the left lower extremity. On 08/09/2021, the hematoma to the left lower leg required surgical intervention (Incision and Drainage). 4. The facility assessed Resident #3 on 01/17/2021, to have a history of falls prior to admission and on 06/23/2021, to require extensive assistance and the physical assistance of one (1) person with transfers. Review of the facility's falls incident reports, from 02/06/2021 to 10/03/2021, revealed Resident #3 had experienced six (6) falls. Three (3) falls from bed and three (3) falls in the bathroom while attempting to toilet or clean-up after an incontinent episode. Per record review, the resident suffered bruising to the right hip and some edema to his/her sacrum area. However, the facility failed to determine the root cause of the falls and implement interventions to prevent further falls. 5. The facility placed an air mattress on Resident #10's bed on 09/19/2021 due to his/her skin breakdown. However, the facility failed to ensure the alternating pressure relief air mattress utilized by the resident was set up, monitored, and operated in accordance with the Manufacturer's guidelines. 6. Additionally, the facility placed an air mattress on Resident #17's bed, on 12/01/2020 due to his/her skin breakdown. However, the facility failed to ensure the alternating pressure relief air mattress utilized by the resident was set up, monitored, and operated in accordance with the Manufacturer's guidelines. 7. The facility assessed Resident #5 to require the use of a mechanical lift. On 08/26/2021 at 11:59 PM the resident was found by staff in his/her room on the floor adjacent to the bed. Facility staff transferred the resident back to bed without the use of a mechanical lift. 8. The facility assessed Resident #6 on 08/04/2021, to require a mechanical lift with two (2) person assist for transfers; however, on 07/06/2021, Resident #6 sustained a fall while being transferred from the bed to chair by two (2) State Registered Nurse Aides (SRNA) without the use of a mechanical lift. The facility's failure to ensure residents were supervised to prevent accidents and failure to ensure the residents' environment remained as free from accident hazards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/12/2021, and determined to exist on 03/18/2020 at 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 10/12/2021. An acceptable Allegation of Compliance was received on 10/21/2021, which alleged removal of Immediate Jeopardy on 10/22/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 10/22/2021 as alleged, prior to exit on 10/28/2021, with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care, F689, at a scope and severity of a E, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Incidents/Accidents/Falls, undated, revealed the facility would ensure that accidents and incidents, involving residents would be identified, reported, investigated, and resolved. Further review revealed all falls would have a site investigation by appropriate staff to define the root cause of the fall to help provide information to enable staff to roll out interventions to prevent another similar occurrence, noting each fall needed a new intervention rolled out. Continued review revealed some occurrences would require a more extensive investigation process that included, falls with significant injury and any fracture. 1. Review of Resident #15's clinical record revealed the facility admitted the resident on 04/16/2015 with diagnoses of Hemiplegia and Hemiparesis of Left Non-dominant side related to Cerebral Vascular Accident (CVA), Chronic Obstructive Pulmonary Disease (COPD), Polyosteoarthritis and Alzheimer's Dementia. Review of Resident #15's Falls Risk Assessment, dated 03/10/2021, revealed Resident #15 scored a nine (9), indicating the resident was at moderate risk for falls. Review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #15 to require one (1) person staff assist for all transfers, toileting, and to ambulate in his/her room and/or on the unit. Further review of the assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was cognitively intact. The MDS revealed the resident had an history of falls. Review of Resident #15's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Further review revealed the resident required the assistance of two (2) staff for transfers and toileting and had a history of falls. Review of Resident #15's Fall Comprehensive Care plan, dated 12/05/2017, revealed a focus area for serious injury related to falls with a goal to remain from further future serious injury from falls. Further review revealed interventions that included: the resident's bed in lowest position for safe transfers; call light in reach when in bed; and, to keep his/her room clean, neat and clutter free. Continued review revealed interventions, dated 11/11/2019, to keep a fall mat to the exit side of the bed and interventions, dated 12/06/2019, to cue the resident to use the call light for safety needs. Continued review of the resident's Comprehensive Care plan revealed the care plan was updated, on 06/02/2021, with interventions which included to add bright colored tape to the resident's call bell, to keep frequently used personal items at bedside, night light in room, and assist of one (1) person for bed mobility, toileting and transfers. Further review revealed, a sign was posted in the resident's room to remind the resident to use his/her call bell for assist. Additionally, interventions were added to the resident's Falls Comprehensive Care Plan, on 06/24/2021, for a foam pommel cushion, anti-rollbacks, left leg rest, anti-tipper to rear of his/her wheelchair and dysom under cushion to wheelchair. Review of Resident #15's incident reports dated 02/18/2020 through 06/02/2021 revealed he/she had a total of sixteen (16) falls at the facility. Continued review revealed eleven (11) falls occurred while the resident was attempting to toilet himself/herself on the following dates: 02/18/2020, 04/10/2020, 04/26/2020, 07/09/2020, 07/11/2020, 10/17/2020, 02/02/2021, 03/27/2021, on 03/31/2021 there were three (3) occurrences, and one on 06/02/2021. However, there was no evidence the facility conducted a thorough investigation of each of Resident #15's falls to determine the root cause of the falls. In addition, there was no evidence the facility tracked/trended the resident's falls and identified that the resident had at least eleven (11) falls while attempting to toilet in order to implement interventions to prevent further falls. Review of the facility's Falls Incident Report, dated 03/27/2021 at 7:58 PM, completed by Licensed Practical Nurse (LPN) #12, revealed Resident #15 rang the call bell. The resident was observed lying on his/her left side on the bathroom floor with a purplish abrasion noted to the left buttock and blood noted under his/her nails to the third (3rd) and fourth (4th) digits of his/her right hand. The resident stated he/she was moving from the toilet to his/her wheelchair and slid to the floor, hitting his/her left buttock on the footrest of the wheelchair. Further review of the incident report revealed no significant injuries were noted. The resident's family, physician, and the Director of Nursing (DON) were notified. Review of Resident #15's Falls Risk Assessment, dated 03/27/2021, revealed the resident scored fifteen (15), indicating he/she was a high risk for falls. Review of Resident #15's Comprehensive Care Plan, dated 03/27/2021, revealed the resident's care plan was revised to educate the resident to make sure the back of his/her legs were touching the wheelchair before sitting down. However, there was no documented evidence the facility completed a root cause analysis of the resident's fall. Interview with Licensed Practical Nurse (LPN) #12, on 10/05/2021 at 8:40 PM, revealed she provided care to Resident #15, on 03/27/2021, from 7:00 PM to 7:00 AM and was working when Resident #15 fell . She stated the resident was frequently reminded to use his/her call bell. Per interview, the resident often attempted to go to the bathroom unassisted. Continued interview revealed that after the resident's fall, she was not interviewed, and the facility did not ask her to submit a statement related to the resident's fall. LPN #12 stated the facility did not investigate the resident's fall, other than the incident report she completed. Record review revealed no documented evidence the facility completed a thorough investigation, to include determining the root cause of the resident's fall. Review of the facility's fall incident report, dated 03/31/2021 at 3:30 AM, revealed Resident #15 had an unwitnessed fall, rang the call light, and was observed by staff to be sitting on a mat beside his/her bed, holding onto his/her bed rail. Per the report, the resident stated to staff he/she was trying to use his/her urinal and his/her feet got tangled. Staff noted urine was spilled onto the floor and on the resident. No injuries were noted. The resident was lifted from the floor by staff and set into his/her wheelchair. Review of the resident's Fall Risk Assessment, dated 03/31/2021 at 4:50 AM, revealed the facility assessed Resident #15 to have a score of fifteen (15), which indicated the resident was at high risk for falls. Further review of the incident report revealed no documented evidence the facility completed a root cause analysis to include a toileting program and/or increased monitoring for the resident. Review of the facility's fall incident report, dated 03/31/2021, revealed Resident #15 had a second (2nd) unwitnessed fall at approximately 3:40 AM, ten (10) minutes after the initial fall. Staff observed the resident sitting on his/her floor mat beside the bed with his/her head and back against the end table. Per the incident report, the resident was confused and stated to staff he/she thought he/she was in Alaska on a boat. Staff noted injuries of bruising to the left side of the resident's neck, bruising to the left hip, and swelling of the left lower leg. Review of the resident's Fall Risk Assessment, dated 03/31/2021 at 2:40 PM, revealed the facility assessed Resident #15 to have a score of sixteen (16), which indicated the resident was a high risk for falls. Further review of the incident report, dated 03/31/2021, revealed interventions were added to put grip strips under the fall mat by the resident's bed and to send Resident #15 to the emergency room (ER). Review of Resident #15's hospital emergency room (ER) record, dated 03/31/2021, revealed when Resident #15 arrived at the hospital at 5:09 AM, the hospital staff evaluated the resident for left hip and leg pain. Per the record, the resident had negative x-rays of bilateral hip and pelvis with swelling noted to the left leg shin. Per the record, the hospital discharged the resident back to the facility at 8:30 AM with no significant injuries noted. Further review of the hospital record revealed no x-ray of the resident's left lower leg was noted. Review of the facility's fall incident report, dated 03/31/2021 at 2:50 PM, revealed Resident #15 had a third (3rd) unwitnessed fall after returning from the ER. Per review, staff heard the emergency bathroom light sounding and found the resident lying on the floor in his/her bathroom on his/her left side. The resident stated to staff he/she was going to the bathroom and could not make it when he/she fell . Per the resident, he/she landed on his/her buttocks and just laid down after pulling the call bell because he/she could not sit up any longer. The resident stated he/she did not hit his/her head but complained of left leg pain due to hospital staff turning it that morning after his/her prior fall. Review of Resident #15's fall incident report, for his/her third (3rd) fall, on 03/31/2021, revealed the resident was assessed with no new injuries. An intervention was added for therapy to evaluate the resident due to increased weakness in his/her bilateral extremities. However, there was no documented evidence the facility identified a root cause. Interview with Resident #15, on 09/28/2021 at 4:32 PM, revealed he/she was attempting to use the bathroom when he/she fell and broke his/her leg. The resident stated he/she fell and broke his/her leg twice (2), trying to use the bathroom. The resident stated he/she did not recall the details of the events, only that he/she fell in the bathroom and had to go to the hospital. Resident #15 stated he/she does not get up now and has not had any recent falls. Interview with Licensed Practical Nurse (LPN) #5, on 10/04/2021 at 3:50 PM, revealed she provided care to Resident #15 from 7:00 AM to 7:00 PM during day shift, on 03/31/2021. She stated Resident #15 had two (2) prior falls that morning and had returned from the ER with no fractures noted. She stated at approximately 2:50 PM, Resident #15 attempted to get up and use the urinal and fell for a third (3rd) time that day. She stated the resident would frequently attempt to toilet himself/herself unassisted and required one (1) staff assist at the time of the falls. She further stated Resident #15 was not on a toileting program or increased supervision, but toileting every hour would have helped with preventing his/her the falls, as well as, implementing increased supervision. Per interview, LPN #5 revealed that when residents continued to have reoccurring falls, without implementing additional interventions, the residents would be at risk for serious injury and/or death. An additional interview with LPN #12, on 10/05/2021 at 8:40 PM, revealed that after Resident #15's fall, on 03/31/2021, no increased monitoring was implemented. She further stated she did not recall the resident on a toileting program, but the resident had periods of incontinence prior to fracturing his/her leg. The LPN stated the resident was now more incontinent since the injury and required a Hoyer (brand of mechanical lift) lift. Interview with State Registered Nursing Assistant (SRNA) #12, on 10/04/2021 at 9:34 PM, revealed she worked on 03/31/2021 and provided care to Resident #15 from 7:00 PM to 7:00 AM during night shift. She stated, the resident had back-to-back falls, adding she worked when the resident experienced his/her first (1) and second (2nd) falls. Per interview, she stated she was charting and suddenly heard a loud clunk. The SRNA revealed she ran into Resident #15's room and found the resident on his/her floor mat beside his/her bed. She stated the resident was confused that night and thought he/she was in Alaska. SRNA #12 stated she went into the resident's bathroom to retrieve a wet washcloth, to clean the resident up. Further, she stated Registered Nurse (RN) #4 obtained paperwork to document the resident's fall. Continued interview with SRNA #12, on 10/04/2021 at 9:34 PM, revealed that while she was in the bathroom with the resident, she observed the resident attempting to stand up and he/she fell again. SRNA #12 further stated Resident #15's left lower leg looked bad and the resident complained of pain. Per interview, the resident was sent to the emergency room (ER) for an evaluation. She stated the resident had a history of being non-compliant with ringing his/her call bell for assistance and he/she had frequent falls attempting to ambulate unassisted to the bathroom. SRNA #12 stated she did not recall the resident being placed on increased monitoring and/or being placed on a toileting program, prior to and/or after the resident's falls. Interview with Registered Nurse (RN) #4, on 10/05/2021 at 11:30 PM, revealed he was working on the night shift (7:00 PM to 7:00 AM), starting on 03/30/2021 to 03/31/2021, when Resident #15 had two (2) falls. He stated the resident fell from his/her bed onto the fall mat beside the bed initially, then staff assisted the resident from the floor to his/her wheelchair at the resident's request. The RN stated he could not recall what the resident was attempting to do at the time of the fall. RN #4 stated the second fall occurred shortly after the resident was assisted to his/her wheelchair. Further interview with RN #4, on 10/05/2021 at 11:30 PM, revealed the resident struck the footrest of his/her wheelchair when the second fall occurred. He stated the resident's left lower leg looked bad. The RN stated there was a knot below the resident's knee cap. Continued interview revealed the resident was sent to the ER for evaluation and the resident's injuries were reported to the ER staff. The RN stated he did not recall Resident #15 being placed on increased monitoring or a toileting program after his/her falls on 03/31/2021. RN #4 stated the resident had an increase in pain management following the falls, which was effective. Interview with LPN #12, on 10/05/2021 at 8:40 PM, revealed she could not recall exactly what Resident #15 was doing at the time of the fall, but the resident had no significant injuries. Per interview, she stated the resident's left knee and ankle were swollen from his/her falls, on 03/31/2021. LPN #12 stated when a resident experienced a fall, the nurse was responsible for completing an incident report with a fall risk assessment, provide a head-to-toe assessment, and the physician, resident's family, and the Director of Nursing (DON) would be notified. Review of Resident #15's Nursing Notes, dated 04/01/2021 at 10:39 AM, revealed Licensed Practical Nurse (LPN) #5 noted a change in condition for Resident #15. LPN #5 assessed the resident's lower extremity to have redness, warmth, and edema (swelling). The LPN notified the Advanced Practice Nurse Practitioner #1(APRN). Interview with LPN #5, on 01/04/2021 at 3:50 PM, revealed Resident #15 complained of pain with movement on 04/01/2021 and had swelling in the left lower extremity with a red raised area on the left shin. Per the LPN, she notified APRN #1 of the resident's change in condition, and the resident was placed on antibiotics for cellulitis. Review of Resident #15's Physician's Orders, dated 04/01/2021, revealed orders for Bactrim DS (antibiotic) two (2) times daily for seven (7) days and Florastor (probiotic) supplement for fourteen (14) days for treatment of cellulitis of left lower extremity. Interview with Advanced Practice Registered Nurse (APRN) #1, on 10/07/2021 at 2:08 PM, revealed she was in the facility five (5) days a week and assessed Resident #15 on the afternoon of 03/31/2021 following the third (3) fall. She stated on 04/01/2021, the nurse, LPN #5, notified her of redness, swelling and warmth to the resident's left lower extremity and she saw Resident #15 at the facility. APRN #1 stated after assessing the resident's leg, she suspected cellulitis and ordered antibiotic therapy, and did not recall Resident #15 complaining of pain, on 04/01/2021, at the time she examined him/her. She further stated, she returned to the facility on [DATE] and reassessed Resident #15's left lower extremity, at which time, she observed the leg to be discolored, painful, and ordered additional x-rays at the to rule out a fracture. She stated the mobile x-ray results revealed a left tibia, fibula, and patellar fracture. Per interview, she sent Resident #15 out to the ER for further evaluation. Review of Resident #15 hospital record, dated 04/05/2021, revealed the resident presented to the ER with a chief complaint of left tibia/fibula fracture and acute knee injury related to a fall. Further review revealed an x-ray of the left lower extremity had a transverse, minimally distracted fracture of the patella, comminuted fracture of proximal tibial shaft, and comminuted fracture of proximal fibula. The hospital admitted Resident #15 for an orthopedic surgical consult. Per review, the resident was deemed not a candidate for surgical intervention and was discharged back to the facility, on 04/07/2021, in a long leg splint with knee immobilizer. Further review of Resident #15's record revealed the resident was in the leg splint with knee immobilizer until 05/31/2021, when it was discontinued. Review of the facility's, Fall incident report, dated 06/02/2021 at 11:15 AM, revealed staff heard Resident #15 yelling for help and upon entering the resident's room, staff observed the resident laying on the bathroom floor. Upon assessment, the resident's left leg was noted to be twisted one-hundred and eighty (180) degrees behind him/her with his/her foot pointing backwards. Resident #15 told staff he/she was attempting to self-transfer to the toilet at the time of the fall. The facility sent Resident #15 to the ER via ambulance for further evaluation. Further review revealed a new intervention was put in place, to post a sign in the resident's room to remind him/her to use the call bell for assistance. However, continued record review revealed there was no documented evidence the facility identified the root cause of Resident #15's fall, to include interventions that would provide increased monitoring and/or placed on a toileting program to decrease the resident's falls. Interview with Licensed Practical Nurse (LPN) #3, on 10/11/2021 at 5:34 PM, revealed she provided care to Resident #15, on 06/02/2021, when the resident fell . She stated the resident attempted to transfer himself/herself to the bathroom unassisted. LPN #3 stated she heard Resident #15 yelling and found him/her on the bathroom floor upon entering the resident's room. Per interview, the resident's wheelchair was observed within the doorway of the bathroom. She further stated the resident's left lower extremity was twisted behind him/her and she immediately notified the ambulance to send Resident #15 to the ER. LPN #3 stated Resident #15 had a history of getting up out of his/her wheelchair and bed unassisted prior to his/her fall. Review of Resident #15's hospital record, dated 06/02/2021, revealed he/she arrived at the emergency room (ER) at 12:07 PM. Continued review revealed the x-rays noted an acute non-displaced tibial fracture with other healing chronic tibia and fibula fractures. Resident #15 was placed in a knee and ankle immobilizer with ortho-glass (temporary splint cast) and discharged back to the facility with no weight bearing on the left lower extremity. Interview with the Medical Director, on 10/07/2021 at 2:40 PM, revealed he was not aware Resident #15 had sixteen (16) falls since 02/18/2020. He stated he expected the facility to provide a safe environment for the residents, thoroughly investigate falls, and put interventions in place to prevent falls to protect the residents from injury. The Medical Director stated he attended monthly Quality Assurance (QA) meetings and falls were discussed monthly, though root cause analysis of falls was not discussed regularly. He further stated it was concerning Resident #15 had so many falls. The Medical Director stated processes needed to be in place for residents who had recurrent falls. Interview with the Director of Nursing (DON), on 10/06/2021 at 1:50 PM, revealed that when a resident experienced a fall, an investigation would be completed, and she would be contacted to ensure staff came up with appropriate falls interventions for the resident. Further, the DON revealed she was aware Resident #15 had multiple falls related to attempts to self-toilet and/or going to his/her bathroom. The DON stated the resident was non-compliant with his/her interventions. Continued interview with the DON, on 10/06/2021 at 5:08 PM, revealed she tracked and trended falls and the facility looked at what occurred, what the resident was doing at the time of the fall, and the care plan would be reviewed and/or revised. Additionally, the DON revealed she had not identified Resident #15's recurrent falls occurring while attempting to toilet himself/herself, but should have, for the safety of the resident. Interview with Administrator, on 10/06/2021 at 5:55 PM, revealed after a fall occurred, the facility investigated the incident, and an intervention would be put into place. He further stated falls were then reviewed in the clinical morning meetings, monthly Quality Assurance meetings, and the resident's care plans were also reviewed. When asked what potential outcomes could occur for residents who had recurrent falls, he stated the residents who had falls were at risk for serious injury or death. Further interview revealed it was the facility's responsibility to provide a safe environment for residents and ensure they were free from accidents or injury. 2. Review of the facility's policy titled, Low Air Loss Mattress, undated, revealed the low air loss mattress should be placed on the resident's bed by housekeeping or maintenance. The policy also stated when the mattress was initiated for use maintenance or housekeeping would ensure the pump and mattress overlay were in good working order and nursing staff would allow twenty-five (25) to forty (40) minutes for the mattresses to totally inflate. According to the policy, the use of a low air loss mattress could be required as part of the resident's treatment plan. However, the policy provided no direction to staff on ensuring the mattress was set on the appropriate setting based on the resident's weight, or what ongoing monitoring was required when a resident utilized an air mattress. Review of the manufacture's guidelines, entitled, Alternating Pressure Low Air Loss Mattress System, undated, revealed the mattress, utilized by Resident #16, had adjustable settings that allowed for customized pressure by use of the resident's weight. Review of the facility's policy titled, Selectis Alternating Pressure Pump and Mattress-User Manual, undated, revealed general maintenance for the mattress included to check the power cord and plug to see if there were abrasions or excessive wear. The manual also stated that the mattress covers should be checked for signs of wear or damage, and staff should ensure the mattress cover and tubes were connected correctly. According to the manual, general maintenance included for staff to check the air hoses to ensure there were no kinks or breaks. The manual also stated general maintenance of the mattress also included to check the pump unit and ensure both power indicators were off when the switch was turned to the off position. Review of the facility's policy titled, Side Rails/Enabler Bars undated, revealed it was the policy to provide a process for licensed medical staff to evaluate, document the needs with the necessary interventions related to the use of side rails. The policy stated staff would complete a side rail screen and list the alternatives attempted prior to the discussion for side rail utilization, and why those attempts failed or were not appropriate for the resident. According to the policy, staff were required to provide education for the resident and/or the responsible party regarding the risk of utilizing side rails, which included risks of entrapment/death. Further review of the Side Rails/Enabler Bars policy revealed staff were to obtain a signed consent for the utilization of the side rails. Further, the policy indicated side rails should be checked at least quarterly as part of the preventive maintenance program for loose fit and functionality. Further review revealed there should be no more than four and three fourths (4 3/4) inch gap within the rails themselves or between the rails and any part of the mattress or bed frame. Additionally, review of the policy revealed, staff were [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement care plans for three (3) of fourteen (14) sampled residents (Residents #16, #7 and #6). On 03/18/2020, the facility placed Resident #16 in a bed with a bed rail designed to assist the resident with bed mobility. On 03/28/2020, the facility placed an alternating pressure relief air mattress (a mattress that inflates and deflates) to relieve pressure due to the resident's risk for skin breakdown. However, the facility failed to develop a plan of care addressing the use of the bed rails and the air mattress; and, failed to develop interventions to ensure the safety of Resident #16. On 08/28/2021, Resident #16 sustained a fall from the bed. Staff interviews and record review revealed the resident's right arm was entrapped in the bed rail and mattress and the lower part of the resident's body was on the floor. According to staff, the resident's right arm was trapped between the bed rail and mattress and staff were unable to free the resident's arm, until two (2) staff members removed the mattress from the bed frame. The facility assessed Resident #7 to require the total assistance of two (2) staff for transfers and care planned the use of a Hoyer lift (brand of mechanical lift) for transfers. However, the facility failed to ensure staff utilized the Hoyer lift when transferring the resident on 07/23/2021. During the transfer, staff lowered Resident #7 to the floor and the resident sustained a fracture to the left foot, fifth (5th) digit and a hematoma to the left lower extremity. On 08/09/2021, the hematoma to the left lower leg required surgical intervention (Incision and Drainage). Additionally, the facility assessed Resident #6 to require a mechanical lift for transfers and the facility care planned for the use of a Hoyer lift for transfers. However, on 07/06/2021, two (2) staff transferred the resident without using a lift, resulting in staff lowering the resident to the floor. The facility's failure to ensure residents' care plans were developed to include potential risks involved with the use of side rails and air mattresses has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/12/2021, and determined to exist on 03/18/2020 at 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656. The facility was notified of the Immediate Jeopardy on 10/12/2021. An acceptable Allegation of Compliance/Removal Plan was received on 10/21/2021, which alleged removal of Immediate Jeopardy on 10/22/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 10/22/2021 as alleged, prior to exit on 10/28/2021, with remaining non-compliance in the area of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656, at a scope and severity of a D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, not dated, revealed the resident's comprehensive care plan would expand on the resident's risks, goals and interventions utilizing the Person-centered plan of care approach for each resident which included measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. Continued review revealed, These needs will be defined from observation, interviews, clinical medical record review and through assessments and Care Area Assessments (CAA). The Physician's Orders, Medication Administration Record (MAR) and Treatment Administration Records (TAR) were extensions of the Plan of Care. The facility's Interdisciplinary Team (IDT) in conjunction with the resident, resident's family, surrogate or representative as appropriate, along with a hands on caregiver, such as a Certified Nursing Assistant (CNA) would discuss and develop quantifiable objectives along with appropriate interventions. Further review of the policy revealed, care plans were developed in an effort to achieve the highest level of functioning and overall well-being attainable for the resident. Review of the facility's policy titled, Side Rails/Enabler Bars, undated, revealed the policy was intended to provide licensed medical staff with a process for evaluating and documenting on the needs and necessary interventions related to the evaluation of side rails used in the facility. Review of the manufacture's guidelines for the mattress utilized by Resident #16, not dated, revealed the settings were adjustable, by the resident's weight, which allowed for a customized pressure for the residents. Interview, on 10/06/2021 at 4:50 PM, with the mattress supplier's Account Sales Manager, revealed his supply company provided the mattress utilized by Resident #16. He stated to ensure the mattresses were utilized safely, staff should first know the current weight of the resident. He also stated if a resident weighed two-hundred and seventy-six (276) pounds, the mattress pressure pump should be set between two-hundred (200) and three-hundred (300) pounds. Further, he stated that when the pressure pump was not adjusted to the residents' weight accurately, as per the manufacture's guidelines, then the residents' would would be at risk for harm, injury, and potentially death. 1. Review of Resident #16's medical record revealed the facility admitted the resident on 02/27/2020 with diagnoses, which included Peripheral Vascular Disease and Acquired Absence of left and right legs below the knee. Further review of Resident #16's record indicated he/she weighed two-hundred and seventy-six pounds (276), on 09/28/2021. Review of Resident #16's Quarterly Minimum Data Set (MDS) Assessment, dated 07/26/2021, revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Continued review of the resident's MDS revealed he/she required the assistance of two (2) staff members with toileting and bed mobility. Review of Resident #16's most recent Significant Change MDS Assessment, dated 10/03/2021, indicated he/she was cognitively intact, with a BIMS score of fifteen (15). The assessment also revealed the resident required the assistance of two (2) staff members for bed mobility and toileting needs. Review of Resident #16's comprehensive care plan indicated staff placed an air mattress on his/her bed on 03/28/2020, related to his/her risks of skin breakdown. However, review of his/her care plan last reviewed/revised on 09/28/2021, revealed the facility failed to develop a care plan to include interventions related to the potential risks involved with the use of the air mattress. Further review of the care plan revealed staff were to check the function of his/her air mattress each shift; however, the care plan failed to direct staff on how to conduct the function checks of the air mattress. Continued review of Resident #16's care plan revealed on 03/18/2020 staff developed a care plan related to his/her potential for serious injury from side rail use/fall due to medical conditions which included; his/her right and left below the knee amputations; and, his/her dependency on staff for toileting and bed mobility. Review of the care plan interventions implemented on 03/18/2020 related to the use of side rails indicated the care plan only stated that the resident utilized a quarter (1/4) inch side rails, per Physician's Orders, to aid with his/her mobility. However, no interventions were developed related to the potential risks involved with the utilization of side rails. Review of Resident #16's Fall incident report dated 08/28/2021 at 12:33 AM revealed Resident #16 was hollering out and staff observed the resident lying on his/her side, on the floor and his/her right arm was stuck in between the rail. The report also revealed the resident informed staff he/she was reaching for his/her cell phone and rolled off onto the floor. Interview with Resident #16, on 09/30/2021 at 11:30 AM, revealed the resident dropped his/her cell phone on the floor and when he/she tried to lean over to retrieve the phone, he/she rolled out of bed. Resident #16 stated his/her right arm was stuck in the side rail and mattress. Further interview with the resident revealed staff had to take his/her mattress off the bed, to get his/her arm out. The resident stated no one informed him/her of any risks involved with the use of an air mattress and/or side rails. Interview with Licensed Practical Nurse (LPN) #8, on 10/05/2021 at 12:00 PM, revealed she cared for Resident #16 when the resident fell from the bed on 08/28/2021. She stated she observed the resident's lower body on the floor, and his/her right arm was stuck between the bed rail and the air mattress. According to the LPN, two (2) staff members had to remove the mattress from the bed frame, to free his/her right arm from being stuck. Further, she stated she was unaware she had to monitor the settings on the resident's mattress. Continued interview with LPN #8 revealed she was not responsible for the development of the resident's care plan. Interview with LPN #10, at 2:25 PM on 10/04/2021, revealed she frequently cared for facility residents that utilized side rails and/or air mattresses. LPN #10 stated she was not directed on how to ensure residents were free from the potential risks involved with the use of an air mattress and/or side rails. Interview with the Minimum Data Set (MDS) nurse, on 10/06/2021 at 11:25 AM, revealed she was responsible for the development of the residents' care plans in the facility. Continued interview revealed she developed Resident #16's care plan. Further, she stated she did not find any concerns related to the interventions implemented in the resident's care plan. However, revealed she was unaware of the potential risk (injury, physical harm, or death) with the utilization of the side rails and/or air mattresses without implementing appropriate interventions. Interview with the Director of Nursing (DON) at 1:55 PM, on 10/06/2021, revealed MDS staff was responsible for the development of the residents' care plans. However, stated she had no concerns with Resident #16's care plan because she did not feel the use of the air mattress and/or side rails posed any potential risks for the residents. Interview with the Administrator on 10/06/2021 at 1:50 PM, revealed MDS staff was responsible for ensuring the residents' care plans were developed appropriately. Further, he stated he had no system in place to ensure care plans were developed to include the use of devices or the potential risks posed to the residents, but should have, as per the facility's policy and manufacture's guidelines. 44371 2. Review of Resident #7's medical record revealed the facility admitted the resident, on 08/17/2020, with diagnoses of Chronic Congestive Heart failure, Atherosclerotic Heart Disease, Hypothyroidism and Chronic Kidney Disease. Review of Resident #7's Annual Minimum Data Set (MDS) Assessment, dated 05/18/2021, revealed the facility assessed Resident #7 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Further review of the MDS revealed the resident was totally dependent and required two (2) person physical assist with transfers. Review of Resident #7's Comprehensive Care Plan revealed the facility had addressed that the resident had the potential for serious injury/falls with interventions which included a therapy recommendation for a Hoyer lift (brand of mechanical lift) for transfers due to the resident's unpredictable desire to bear weight or assist with transfers. The interventions were initiated on 03/05/2021. The Activities of Daily Living (ADLs) portion of the resident's care plan also included the use of the Hoyer lift with transfers and using two (2) staff assist, initiated on 06/01/2021. Review of Resident #7's Kardex (the nurse aide care plan), revealed the Kardex was not dated when interventions were added. The Kardex currently included directions for staff to transfer the resident with two (2) person assist using a Hoyer lift. Review of the incident report, dated 07/23/2021 at approximately 7:06 PM, revealed two (2) staff members attempted to transfer Resident #7 from the wheelchair to the bed when the resident lifted his/her feet off the floor causing staff to take the full weight of the resident during transfer. Per the incident report, staff lowered the resident to the floor on his/her knees and then back into the wheelchair while one (1) staff went to get help. Following the incident, staff assessed the resident to have a large hematoma to the left lower leg. The facility staff notified the physician and the physician ordered mobile x-rays. Interview with State Registered Nursing Assistant (SRNA) #5, on 09/16/2021 at 12:01 PM, revealed on the day of the incident (07/23/2021), she and State Registered Nursing Assistant #6 attempted to transfer Resident #7 from the wheelchair to bed. Per interview, the SRNA stated she put her knees against the resident's knees to prevent the resident from sliding out of the wheelchair as the resident was not all the way in the wheelchair just barely on the seat and SRNA#6 went to get help. Staff transferred the resident to bed with the help of three (3) or four (4) staff, without using a lift. The SRNA stated Resident #7 was a two (2) person assist until the incident happened. However, review of the care plan revealed two (2) person assist with a mechanical lift was added to the care plan on 03/05/2021, before the incident. She stated she failed to review the Kardex before transferring the resident. SRNA #5 stated it was very important to review the Kardex before taking care of any resident. She stated she should have reviewed it prior to helping the other staff transfer the resident back to bed Interview with SRNA #6, on 09/17/2021 at 3:12 PM, revealed SRNA #5 asked her to help transfer Resident #7. The SRNA stated when she and SRNA #5 were transferring Resident #7 from the wheelchair to the bed, the resident bent his/her legs with his/her feet under his/her bottom. The SRNA stated this put all of the resident's weight on them so they eased the resident down to the floor, but were able to get the resident back into the wheelchair. SRNA #6 stated it took four (4) staff to get the resident back into the bed. She stated the resident was care planned as a (2) person staff assist, but after this incident happened, the resident was to be transferred with a lift. SRNA #6 stated SRNA#5 told her that she and another SRNA (could not remember SRNA's name) had transferred the resident earlier in the day with the use of a lift. Interview with LPN #3, on 09/17/2021 at 2:55 PM, revealed (2) two SRNA's (SRNA#5 and SRNA #6) transferred Resident #7 from the wheelchair to the bed when the incident occurred. The SRNA's told her Resident #7 had raised his/her legs and feet up behind his/her bottom which put all the resident's weight on the SRNA's. The LPN stated prior to the incident Resident #7 was a two-person assist with transfers. However, interview with Licensed Practical Nurse (LPN) #9, on 09/27/2021 at 9:21 PM, revealed she provided care for Resident #7. LPN #9 stated at the time of the incident, the resident required a Hoyer lift for transfers. The LPN stated Hoyer lifts were available for staff use. LPN #9 stated she updated the resident's Kardex when there were changes. She stated staff were to look at the Kardex to determine what care was to be provided. She stated by reviewing the Kardex, staff would know if the resident was a lift or a two (2) person transfer, etc. Interview with MDS Nurse, on 10/06/2021 at 11:25 AM, revealed care plans were updated after morning meetings and then the Kardex was updated by the Central Supply Clerk. The MDS Nurse stated care plan interventions should be updated with a new intervention(s) after each fall. She stated the Director of Nursing (DON) tracked and trended falls. Per the MDS Nurse, the Kardex was a working tool which staff used to provide resident care. The MDS Nurse stated the facility had identified a concern with care plans and Kardexes. She stated updates and revisions to the care plan were not always being added to both the care plan and the Kardex. Interview with Registered Nurse (RN) #2, on 09/17/2021 at 7:25 PM, revealed the residents' care plans were on the Kardex inside their rooms. The RN stated Resident #7 was a two (2) person assist at the time of the incident and after the incident staff were directed to use the lift. Interview with LPN #8, on 09/27/2021 at 8:59 PM, revealed the resident's care information was located on the Kardex in the residents' rooms and the information could also be found on the computer in their care plans. She stated at the time of the incident Resident #7 required a Hoyer lift for transfers. Interview with the Director of Nursing (DON), on 10/06/2021 at 5:09 PM, revealed she expected staff to follow residents' care plans. She stated there was a risk for severe negative outcome if staff did not use the Hoyer lift. The DON stated the resident or staff could be injured. She stated before staff cared for the resident, they were to review the Kardex in the resident's room so they could provide the assistance or support per the care plan. Interview with Administrator on 10/06/2021 at 5:56 PM revealed he expected staff to follow care plans. He stated not using Hoyer lifts for transfers had the potential risk for injury for residents. 45201 3. Review of Resident #6's medical record revealed the facility admitted the resident on 08/19/2020 with diagnoses of Hemiplegia, Cerebral Vascular Accident (CVA), and Hemorrhage affecting left non dominant side. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was moderately impaired cognitively. Continued review of the assessment revealed the resident required a mechanical lift with two (2) person assist for transfers. Review of Resident #6's Comprehensive Care Plan under the section for Activities of Daily Living revealed an intervention dated 04/07/2021, for staff to utilize a mechanical lift with two person assist for transfers. Review of Resident #6's Kardex not dated, revealed the resident required a lift with two person assist for transfers. Review of the facility's incident report revealed on 07/06/2021, Resident #6 sustained a fall while being transferred from the bed to chair. Per the incident report, the resident willingly set down while being transferred by State Registered Nurse Aide (SRNA) #7 and SRNA #8. The report stated staff assessed the resident to have no injuries after the fall. Observation of Resident #6, on 09/27/2021 at 3:39 PM, revealed the resident was in bed. Interview with Resident #6, on 09/27/2021 at 3:40 PM, revealed the resident remembered the incident on 07/06/2021. Resident #6 stated SRNA #7 and SRNA #8 tried to transfer him/her from the bed to wheelchair without using a lift. The resident stated when they lifted him/her, he/she was weak, and they lowered him/her to the floor and then into the wheelchair. Resident #6 stated he/she was always transferred using a lift but the SRNA's did not use a lift on that day. Interview with State Registered Nurse Aide (SRNA) #8, on 09/21/2021 at 3:19 PM, revealed she remembered the incident on 07/06/2021. The SRNA stated they were transferring the resident from the bed to wheelchair, when they lifted the resident, he/she was weak, and they lowered the resident to floor and then into the wheelchair. The SRNA stated the resident was not injured and had no complaints of pain after the incident. SRNA #8 stated the resident was a two person assist for transfers. Interview with SRNA #7, on 09/15/2021 at 2:11 PM revealed she was agency staff and was working at the facility on the day of the incident with Resident #6. The SRNA stated while transferring Resident #6, he/she sat down on them and then was lifted into the wheelchair. SRNA #7 stated Resident #6 was a two person assist for transfers at the time of the incident. She stated after the incident staff were directed to use a lift with two person assist when transferring Resident #6. Interview with Licensed practical Nurse (LPN) #6, on 09/21/2021 at 4:47 PM, revealed she was aware and assessed Resident #6 after the fall on 07/06/2021. The LPN stated Resident #6 sustained a fall while being transferred from the bed to the chair. LPN #6 stated the resident willingly sat down while being transferred by the SRNA#7 and SRNA #8. She stated the resident was assessed to have no injuries and no complaints of pain after the incident. Continued interview revealed she was aware Resident #6 required the assistance of two staff members and a lift for all transfers. She stated she was not aware SRNA #7 and SRNA #8 transferred the resident without using a lift. LPN #6 stated the SRNA's should have looked at the Kardex to determine the level of care to provide the resident. Interview with Director of Nursing (DON), on 10/06/2021 at 5:08 PM and 5:45 PM, revealed she expected nursing staff to follow the residents' care plans and provide appropriate assistance. Continued interview revealed if a resident required a lift and two (2) staff assist and staff did not do provide this care, it could lead to injury of the resident. She further stated she expected staff to look at the resident's Kardex before providing care, and if they did not, it could lead to insufficient assistance and incorrect care provided. Interview with Administrator, on 10/06/2021 at 5:55 PM, revealed he expected nursing staff to be oriented to the needs and level of care for residents before providing care. He stated he expected staff to be trained to identify potential hazards for residents. **The facility implemented the following actions to remove the Immediate Jeopardy on 10/22/2021: 1. Resident #15 and Resident #16 were placed on every fifteen (15) minute checks, on 10/12/2021, while an interdisciplinary team (IDT) review occurred. On 10/13/2021 the Unit Manager (UM)/Registered Nurse (RN) #1 completed a physical assessment of both resident's and no injuries were identified. 2. On 10/15/2021 at 8:14 PM, the Director of Nursing (DON) documented an IDT meeting was conducted and the following people were in the meeting: The DON, Assistant Director of Nursing (ADON), the UM/RN #1, Director of Maintenance , Activities Director, Social Services Director, Physical Therapy Assistant, State Registered Nurse Aide (SRNA) #3 and the Minimum Data Set (MDS) nurse. The IDT completed a review of Resident #15 and Resident #16 related to fall risk, level of necessary supervision, use of assistive devices (including side rails). The IDT also conducted a root cause analysis of Resident #15's fall which occurred on 06/02/2021 and Resident #16's fall which occurred on 08/28/2021. Further, the interdisciplinary team (IDT) reviewed the residents' current fall interventions and determined the every fifteen (15) minute checks were continued. Resident #15 and Resident #16's care plans and nurse aide Kardex were revised by the Minimum Data Set (MDS) nurse during the review. 3. The facility conducted audits from 10/13/2021 to 10/16/2021, which identified residents at risk for falls with potential to be affected by inaccurate fall investigations and identification of root cause analysis. Residents identified as at risk were reviewed by the IDT and the residents' care plans were reviewed, for fall risk, level of necessary supervision, use of assistive devices, and current interventions. The facility audited twenty-one (21) residents with orders for low air loss mattresses. Further, the facility audits determined, sixteen (16) mattresses were discontinued. The audits also identified five (5) residents benefited from the continued use of air mattresses and the risk verses benefit of using a low air loss mattress was discussed with the resident's and/or their responsible parties. Consents were obtained for the continued use of the devices for those five (5) residents. 4. On 10/15/2021, Registered Nurse (RN) #1 completed a side rail and a low air loss mattress assessment on Resident #16 to determine the risk verses benefit for both devices. During the review, the RN determined Resident #16 utilized his/her side rails as an enabler and he/she also benefited from the use of a low air loss mattress. The facility determined the resident's mattress type was changed to a Pressure-Guard low air loss mattress and settings were determined to be appropriate based on manufacturer's guidelines. On 10/15/2021, the risk, which included entrapment, versus the benefit of side rail use as well as the use of a low air loss mattress was reviewed by RN #1 with Resident #16 and his/her responsible party, and consent was obtained to utilize both devices. Further, Resident #16's alternating low air loss mattress was checked for accuracy of settings/function every shift and documented on the medication/treatment record by the nursing staff. Any concerns identified was immediately reported/addressed by nursing/maintenance. 5. The facility conducted audits and assessments on 10/15/2021 and 10/16/2021 by therapy, nursing and maintenance staff of all side rail utilized in the facility. Residents were screened by therapy and assessed for use per the manufacturer's guidelines to ensure residents' safety. Staff reviewed the side rails to determine the following; medical need for the side rail, accurate assessment completed, specific orders, proof of education regarding the risks/benefits of the side rails, consents for use of the side rails, ensure the care plan and nurse aide Kardex reflected the use of the devices, and proper fit and attachment of the side rails. Any resident identified to benefit for the continued use of side rails was evaluated by therapy staff to ensure appropriate use of the device. 6. On 10/18/2021, the IDT conducted a care plan meeting to complete a comprehensive review of Resident #15 and Resident #16's fall risk, level of necessary supervision, use of assistive devices as applicable, and the resident's current interventions to reduce falls, which included but was not limited to the following items: Brief Interview for Mental Status (BIMs) Score, vision, hearing, medications, labs, and pain. The IDT requested follow up laboratory tests for Resident #15 which included a Prostate Specific Antigen (PSA) and a diagnostic test for a Post Void Residual. The team also requested the resident's physician and psychiatric services review of Resident #15's medications. The IDT reviewed Resident #15's and Resident #16's record weekly during the Falls Meeting for a period of at least four (4) weeks to monitor the efficacy of the fall interventions and revised the interventions as needed. 7. Administrative and direct care staff were trained on the regulatory requirements for F689 and F700 which included definition of an accident, environmental hazards, fall analysis, revision of care plans, root cause analysis, appropriate interventions, resident supervision, fall meetings, side rails and low air loss mattress assessments/consents, risk versus benefits, appropriate alternatives, general safety tips for use of mattresses and appropriate settings and the manufacturer's guidelines for air mattresses utilized in the facility. Further, the training also included licensed staff to monitor and document every shift on the treatment record to indicate air mattresses were on the proper settings. Staff knowledge of training conducted was measured by post-test which required a score of one-hundred (100%) percent. All staff that were not trained by 10/21/2021 were required to complete training and post-tests prior to working next scheduled shift. 8. On 10/20/2021, a Side Rail, Fall Prevention/Resident Supervision, Low Air Loss Mattress Quality Review Audit tool was reviewed/accepted by the Quality Assurance Performance Improvement (QAPI) Committee. The audit tools would be completed five (5) times a week for twelve (12) weeks and results of the audits would be discussed in the monthly QAPI meetings. After the initial twelve (12) week review, a minimum of ten (10) residents would be reviewed monthly for falls. Following the initial twelve (12) week audits conducted related to side rails/air mattresses, audits would continue to be conducted twice (2) monthly for all residents which utilized the devices in the facility. All audits would continue to occur until one-hundred (100%) percent compliance had been determined by the QAPI committee. Any identified concerns would be reported to the QAPI committee and corrective action plans would be developed as needed. A regional team member would also attend QAPI to provide oversight and assist in ensuring compliance, monthly for three (3) months. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 10/22/2021 as alleged: 1. Review of Resident #15 and Resident #16's medical record and interview with the Assistant Director of Nursing (DON), on 10/28/2021 at 1:40 PM and Registered Nurse (RN) #1/Unit Manager, on 10/28/2021 at 1:00 PM, revealed on 10/12/2021, Resident #15 and Resident #16 were placed on every fifteen (15) minute checks to increase supervision until the Interdisciplinary Team (IDT) review was completed. Further review and interview with RN #1, on 10/28/2021 at 1:00 PM, revealed she assessed Resident #15 and Resident #16, on 10/13/2021 and no injuries were identified. 2. Review of Resident #15 and Resident #16's medical record and interview with the ADON, on 10/28/2021 at 1:40 PM, and Registered Nurse (RN) #1, on 10/28/2021 at 1:00 PM, revealed on 10/15/2021 at 8:14 PM, an IDT meeting was conducted. Record reviews and continued interviews revealed the IDT team completed a review of Resident #15 related to his/her fall risk, level of necessary supervision, use of assistive devices, which included side rails, and the team also completed a root cause analysis of his/her fall which occurred on 06/02/2021. Further review of the resident's documentation indicated the IDT reviewed the resident's current interventions to reduce falls and the resident's fall related injuries. Documentation in the medical record also revealed the IDT review determined Resident #15 had not fallen in the last ninety (90) days, and staff were to continue every fifteen (15) minute checks during this review. Interview with the ADON, on 10/28/2021 at 8:21 PM, revealed on 10/15/21 the IDT completed a review of Resident #16's fall risk, level of necessary supervision, use of assistive devices which included side rails. Further interview and record review revealed a completed root cause analysis of the fall which occurred on 08/28/2021. Further review/interviews with the ADON and RN #1 confirmed the residents' current interventions to reduce the risk for falls were reviewed and the team determined every fifteen (15) minute checks were to be continued and the residents' care plans were reviewed/revised to indicate the required checks. 3. Review of the facility's audits and interviews with the Assistant Director of Nursing (ADON) at 1:40 PM and Registered Nurse (RN) #1 at 1:00 PM on 10/28/2021, revealed on 10/13/2021, the Director of Nursing (DON) identified residents who had experienced falls within the last thirty (30) days. Continued interviews with the ADON, on 10/28/2021 at 1:40 PM; and the RN #1 at 1:00 PM, revealed the Interdisciplinary Team (IDT) team reviewed the residents' records from [TRUNCATED]

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure three (3) of fourteen (14) sampled residents' (Residents #16, #10, and #17) beds and side rails were assessed and the risks versus benefits were discussed with the residents and/or their responsible parties before the bed rails were utilized. The potential risk included entrapment related to the use of the bed rails. In addition, the facility also failed to properly assess to ensure bed rails did not pose a risk of entrapment before the bed rails were installed on Resident #16's bed. On 03/18/2020, the facility placed Resident #16 in a bed with a side rail designed to assist the resident with bed mobility. On 03/28/2020, the facility placed an alternating pressure relief air mattress (a mattress that inflates and deflates) to relieve pressure due to the resident's risk for skin breakdown. However, the facility failed to ensure either device was appropriately assessed and/or utilized per the manufacture's guidelines, to ensure the safety; and, to reduce the potential risk to Resident #16. (Refer to F689) On 08/28/2021, Resident #16 sustained a fall from his/her bed. Staff interviews and review of the facility's documentation indicated the resident's right arm was entrapped in the bed rail and mattress. The lower part of the resident's body was on the floor. Staff were unable to free the resident's arm, until two (2) staff members removed the mattress from the bed frame. Even though Administrative staff reviewed the 08/28/2021 incident, the facility failed to identify that the bed rails were not properly assessed prior to installation; and, failed to identify the safety hazards of the bed rails. Additionally, the facility added one-quarter side rails to Resident #17's bed on 12/01/2020 and to Resident #10's bed on 08/26/2021 as an enabler to assist with bed mobility. However, the facility failed ensure the bed rails were property assessed prior to installation and failed to identify the safety hazards of the bed rails. The facility's failure to ensure residents were appropriately assessed for bed rail use has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/12/2021, and determined to exist on 03/18/2020 at 42 CFR 483.25 Quality of Care, F700. The facility was notified of the Immediate Jeopardy on 10/12/2021. An acceptable Allegation of Compliance/Removal Plan was received on 10/21/2021, which alleged removal of Immediate Jeopardy on 10/22/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 10/22/2021 as alleged, prior to exit on 10/28/2021, with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care, at a scope and severity of a D, while the facility developed and implemented a Plan of Correction and monitored the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Side Rails/Enabler Bars, not dated, revealed the intent of the policy was to provide licensed medical staff with a process for the evaluation, documentation needs and necessary interventions related to the evaluation of side rails utilized in the facility. According to the policy, staff would complete a side rail screen and would list the alternatives attempted prior to the discussion for side rail utilization, and why they failed or were not appropriate for the resident. The policy directed staff to provide education to the resident and/or the responsible party regarding the risk of utilizing the side rails, which included the risks of entrapment/death and directed staff to obtain a signed consent for the utilization of the side rails. Further review of the facility's Side Rail policy, revealed side rails were to be checked at least quarterly as part of the preventive maintenance program for loose fit and functionality. Per the policy, there must be no more than four and three quarter (43/4) inch gap within the rails themselves or, between the rails and any part of the bed frame or the mattress. According to the policy, the facility should devise its interventions to minimize or eliminate the use of side rails or enabler bars. Review of the facility's policy titled, Preventive Maintenance Program Life Safety Code Documentation, last revised on 06/24/2020, revealed nursing monthly inspections included a complete inspection and measurements of bed entrapment zones and within any open space between the perimeters of the rail, which could present a risk of head entrapment where the recommended space was less than four and three quarters (43/4) inch. The policy also identified a gap between the mattress and the lowermost portion of the rail posed a risk of neck entrapment with a recommended space of less than two and three eight (2 3/8) inches. According to the Preventive Maintenance Program policy, bed systems compliance audits should be conducted by maintenance staff (no timeframe indicated) which included an inspection of the bed frames, ensuring the mattress fit the bed and gaps were no larger than four and three quarters (43/4) inch between the headboard, footboard and sides. The audit tool also revealed electric beds should be assessed to ensure they functioned properly and the footboard/headboard were safe and intact, if the bed had any type of enabler or assist bars and if the mattress and support systems were approved by the auditor. Interview with the Maintenance Director, on 10/05/2021 at 11:35 AM, revealed he had no system in place to regularly maintain side rails in the facility. He stated the only time he evaluated/checked side rails was if he was informed of a concern from nursing staff. Further interview revealed he did not conduct regular measurements on beds, side rails, or mattresses to ensure the bed's dimensions were appropriate for the resident's size and weight. The Director also stated he had not measured the gaps between residents' mattresses and rails to ensure the facility was compliant with the required entrapment zone guidelines. He stated he had never been directed to do so. Continued interview revealed he had not been notified by nursing to evaluate Resident #16's bed, side rails or mattress. He stated he was not aware of the incident which occurred, on 08/28/2021, regarding the resident. 1. Review of Resident #16's medical record revealed the facility admitted the resident, on 02/27/2020, with current diagnoses which included Peripheral Vascular Disease and Acquired Absence of left and right legs below the knee. Review of Resident #16's Quarterly Minimum Data Set (MDS) Assessment, dated 07/26/2021, and the Significant Change MDS Assessment, dated 10/03/2021 revealed the facility assessed the resident to require the extensive assist of two (2) staff with bed mobility. Further review revealed the facility assessed the resident as interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #16's record revealed, on 03/18/2020, the facility implemented one quarter side rails as an enabler to increase the resident's independence while he/she was in bed. Review of Resident #16's Treatment Administration Record (TAR) dated August 2021 (when the incident occurred), September 2021 and October 2021, indicated one-quarter side rails were in use for the resident when in bed as enabler for bed mobility every shift for support and positioning. Further review revealed staff provided their initials to verify the side rails were in use. Review of Resident #16's Progress Notes and the Fall incident report dated 08/28/2021 at 12:33 AM revealed the resident was hollering out and staff observed the resident's right arm stuck in the bed rail and mattress and the rest of his/her body was laying on his/her right side on the floor. According to the notes, Resident #16 informed staff that he/she had reached for his/her cell phone and rolled out of bed onto the floor. The notes indicated Resident #16 complained of pain in his/her right arm. Continued review revealed a diagnostic test was conducted on 08/28/2021 which indicated no injury. Further review of the Falls Incident Report revealed no evidence the resident utilized an air mattress or one quarter side rails when the fall occurred. Observations on 09/30/2021 at 11:30 AM and 4:00 PM revealed Resident #16 had one quarter (1/4) side rails in use to both sides of his/her bed. Continued observations on 10/04/2021 at 11:45 AM, and 10/05/2021 at 10:30 AM, revealed one quarter side rails were in use for the resident. Interview with Resident #16, on 09/30/2021 at 11:30 AM, revealed he/she dropped his/her cell phone on the floor and when he/she tried to lean over to retrieve the phone, he/she fell out of his/her bed. The resident also stated his/her right arm got stuck in the rail and mattress and staff had to take the mattress off the bed to remove his/her arm out of the side rails. Resident #16 also stated he/she used the side rails for bed mobility; however, staff had not informed him/her of any risks involved with utilizing side rails. Observations, on 10/12/2021 at 3:05 PM, revealed Maintenance Staff #2 measured the gap between Resident #16's side rail and air mattress, which indicated there was a three-quarter (3/4) inch opening between the two (2) devices. Interview with Maintenance Staff #2, on 10/12/2021 at 2:55 PM, revealed the facility had no system in place to provide ongoing monitoring/maintenance of beds or bed rails to ensure compliance and safety of the residents. He also stated no measurements had been taken regarding the gaps between the bed rails and mattresses. Review of Resident #16's side rail assessment, dated 08/28/2021 at 7:24 AM (approximately seven (7) hours after the incident occurred) completed by Licensed Practical Nurse (LPN) #6 revealed the resident utilized one-quarter side rails to turn, and required extensive assistance with bed mobility. However, the assessment revealed staff had not measured the side rails to ensure the gaps between the rails; and, the gaps between the side rails and mattress were conducive to the resident's safety. Further review of the side rail assessment revealed a visual review (which included raising the head of the bed to assess the mattress and the side rail) had not been conducted. However, staff marked Yes on the assessment, that a visual review had been performed to assess the gap between the mattress and side rail. Per review, the assessment revealed no concerns had been identified. Recommendations based on the assessment completed, on 08/28/2021, indicated the side rails were not a restraint and would be utilized to enable Resident #16, to attain/maintain his/her highest practicable level. However, interview with Licensed Practical Nurse (LPN) #6, on 10/06/2021 at 10:50 AM, revealed she completed the side rail assessment form for Resident #16 after the resident was found entrapped between his/her side rail and mattress, on 08/28/2021. The LPN stated she was not instructed on how to measure the resident's side rails and mattress, physically or visually to ensure the side rails were safe for the resident's use. LPN #6 stated she marked Yes, on the assessment, on 08/28/2021, indicating she had conducted a visual review and assessed that Resident #16's mattress did not shift or slide to allow for an increased gap between the bed and side rail. Further interview revealed the LPN did not actually measure for gaps in the rails and mattress. Continued interview with LPN #6, on 10/06/2021 at 10:50 AM, revealed she was unsure why she marked Yes on the side rail assessment. She stated she had never been trained on how to complete the assessment and was not aware of the entrapment zone requirements outlined in the facility's policy. LPN #6 stated she had never been instructed on the process of assessing/evaluating residents for alternatives before implementing side rails for the residents. Additionally, she revealed she was not instructed to educate the residents' family members and/or the residents of the potential risks posed to the resident by the use of side rails. The LPN also stated the facility had not instructed her to obtain a signed consent before side rails were utilized. Interview with Licensed Practical Nurse (LPN) #13, on 10/04/2021 at 1:50 PM, revealed she was assigned to care for Resident #16 during the day shift (7 AM-7 PM) on 10/04/2021. LPN #13 stated she was agency staff, and this was her first shift worked at the facility. According to the LPN, she had not been provided training related to the use of side rails. Interview with LPN #8, on 10/05/2021 at 12:00 PM, revealed she cared for Resident #16 when the resident fell from his/her bed on 08/28/2021. According to the LPN, two (2) staff members had to remove the mattress from the bed frame, to free Resident #16's right arm from being stuck. She stated she had not been trained on risks involved with use of side rails for residents and had not considered that the resident was entrapped, even though staff had to remove the air mattress to free the resident from the side rail/mattress when he/she fell on [DATE]. She stated the facility provided no training regarding side rail assessments or entrapment zones or how to ensure side rails were utilized safely for residents. She also stated side rails were utilized frequently for residents in the facility. However, she had never been instructed to inform residents and/or their responsible parties regarding the risks involved or to obtain consent, before utilizing side rails. Interview with the Medical Director, on 10/07/2021 at 2:45 PM, revealed staff informed him of Resident #16's incident which occurred on 08/28/2021 when the resident's right arm was caught in a bed rail and an air mattress. Further interview revealed he expected the facility to implement their policies regarding the use of bed rails. During further interview, the Medical Director acknowledged the potential risks posed to residents if proper processes were not followed regarding the use of bed rails. Interview with the Director of Nursing (DON), on 10/06/2021 at 1:55 PM, revealed she recalled discussing Resident #16's fall which occurred on 08/28/2021. However, the DON stated she was not aware the resident's right arm was entrapped in the side rail and mattress, nor did she know two (2) staff members, removed the air mattress from the bed frame to free the resident's upper extremity. The DON stated she determined the root cause of Resident #16's fall was that the resident dropped his/her phone on the floor and was trying to retrieve it. The DON stated she had not identified the risks posed to the resident with the use of side rails, even though documentation in the medical record indicated his/her arm was stuck between the mattress and bed rail. Interview with the Administrator, on 10/06/2021 at 1:50 PM, revealed he attended some, but not all of the Monday through Friday clinical meetings when falls were discussed. He stated he was not aware Resident #16's right arm was entrapped between the side rail and the air mattress when he/she fell from the bed on 08/28/2021. Per interview, the Administrator stated staff had not obtained informed consents, as directed in the facility's policy, for the use of side rails. Additionally, his expectation would be that the facility's policy would be followed. 2. Review of Resident #10's medical record revealed the facility admitted the resident on 08/26/2021 with diagnoses, which included a history of falling. Review of Resident #10's Admission Minimum Data Set (MDS) Assessment, dated 09/01/2021, revealed the resident required extensive assistance of two (2) staff for bed mobility/transfers. According to the assessment, staff determined the resident was interviewable, with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #10 experienced a fall during the last month, prior to admission into the facility. The MDS also indicated the resident had no falls since admission to the facility. Review of Resident #10's medical record revealed staff placed one-quarter side rails as an enabler, to increase his/her independence with bed mobility on 08/26/2021. Review of Resident #10's Treatment Administration Record (TAR) dated August 2021, September 2021 and October 2021, revealed a nurse's signature was noted on the day/night shift (twice daily) that one quarter side rails were utilized for bed mobility every shift. Observation of Resident #10, on 09/30/2021 at 11:50 AM, revealed he/she had one-quarter side rails in use to both sides of his/her bed. An interview with Resident #10, on 10/04/2021 at 11:55 AM, revealed that he/she had not been educated related to any risks involved with the use of the air mattress. Further observations conducted of Resident #10 and observation of Maintenance Staff #2's measurement of the gap between the side rail and the mattress, on 10/12/2021 at 3:00 PM, revealed there was three-quarter (3/4) inch distance between the two (2) devices. 3. Review of Resident #17's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease and Restless Leg Syndrome. Review of Resident #17's Significant Change MDS Assessment, dated 08/11/2021, revealed the resident required extensive assistance of two (2) staff members with bed mobility and toileting. Further review revealed the facility assessed that the resident was cognitively intact with a BIMS' score of fifteen (15). According to the MDS, he/she had not experienced any falls. Review of Resident #17's medical record revealed one-quarter (1/4) side rails were implemented as an enabler for bed mobility on 12/01/2020. Review of Resident #17's Treatment Administration Record, dated October 2021, indicated a nurse's signature was observed on the day/night shift which indicated one-quarter (1/4) side rails were in use for bed mobility. Observations of Resident #17, on 10/04/2021 at 2:40 PM, revealed the resident had one-quarter (1/4) side rails to both sides of his/her bed. Further observation, on 10/12/2021 at 3:00 PM, of Maintenance Staff #2's measurements of the gap between the side rail and the air mattress indicated there was a three-quarter (3/4) inch gap between the side rail and mattress. An interview with Resident #17, on 10/04/2021 at 2:40 PM, revealed no one at the facility had informed him/her of any potential risks of utilizing side rails. Interview with Licensed Practical Nurse (LPN) #4, on 10/04/2021 at 3:00 PM, revealed she frequently cared for Residents #10 and #17 and other residents that utilized side rails in the facility. According to the LPN, she completed side rail assessments as required documentation in the facility. However, she had not been trained on how to conduct a side rail assessment in regards to safety and measuring gaps between the side rail and mattress, to assist in ensuring side rails were utilized safely for residents in the facility. The LPN also stated the facility had not instructed her to obtain consent or, to notify the resident and/or their responsible parties of any potential risks involved with side rail use, which included the risk of entrapment. Interview with the Director of Nursing (DON), on 10/06/2021 at 1:55 PM, revealed the nursing department did not conduct any measurements or evaluations regarding beds and or side rails utilized in the facility. According to the DON, staff nurses completed side rail assessments for the residents; however, the facility had no specific policy related to how the assessments should be completed. The DON also stated she did not feel the use of the side rails, posed any risks to residents and they were utilized to help the resident with maintaining their mobility. She also stated staff were not expected to inform residents and/or their responsible parties of any risks posed by the use of side rails. The DON stated the facility had no specific consent that should be obtained, related to the use of the side rails. Interview with the Administrator, on 10/06/2021 at 1:50 PM, revealed he was unaware the facility had no system to ensure policies/procedures were followed related to ensuring safe usage of side rails. He also stated he thought the maintenance department was conducting measurements of side rails and mattresses, regarding entrapment zones to ensure the device was utilized properly for the residents. **The facility implemented the following actions to remove the Immediate Jeopardy on 10/22/2021: 1. Resident #15 and Resident #16 were placed on every fifteen (15) minute checks, on 10/12/2021, while an interdisciplinary team (IDT) review occurred. On 10/13/2021 the Unit Manager (UM)/Registered Nurse (RN) #1 completed a physical assessment of both resident's and no injuries were identified. 2. On 10/15/2021 at 8:14 PM, the Director of Nursing (DON) documented an IDT meeting was conducted and the following people were in the meeting: The DON, Assistant Director of Nursing (ADON), the UM/RN #1, Director of Maintenance , Activities Director, Social Services Director, Physical Therapy Assistant, State Registered Nurse Aide (SRNA) #3 and the Minimum Data Set (MDS) nurse. The IDT completed a review of Resident #15 and Resident #16 related to fall risk, level of necessary supervision, use of assistive devices (including side rails). The IDT also conducted a root cause analysis of Resident #15's fall which occurred on 06/02/2021 and Resident #16's fall which occurred on 08/28/2021. Further, the interdisciplinary team (IDT) reviewed the residents' current fall interventions and determined the every fifteen (15) minute checks was continued. Resident #15 and Resident #16's care plans and nurse aide Kardex were revised by the Minimum Data Set (MDS) nurse during the review. 3. The facility conducted audits from 10/13/2021 to 10/16/2021, which identified residents at risk for falls with potential to be affected by inaccurate fall investigations and identification of root cause analysis. Residents identified as at risk were reviewed by the IDT and the residents' care plans were reviewed, for fall risk, level of necessary supervision, use of assistive devices, and current interventions. The facility audited twenty-one (21) residents with orders for low air loss mattresses. Further, the facility audits determined, sixteen (16) mattresses were discontinued. The audits also identified five (5) residents benefited from the continued use of air mattresses and the risk verses benefit of using a low air loss mattress was discussed with the resident's and/or their responsible parties. Consents were obtained for the continued use of the devices for those five (5) residents. 4. On 10/15/2021, Registered Nurse (RN) #1 completed a side rail and a low air loss mattress assessment on Resident #16 to determine the risk verses benefit for both devices. During the review, the RN determined Resident #16 utilized his/her side rails as an enabler and he/she also benefited from the use of a low air loss mattress. The facility determined the resident's mattress type was changed to a Pressure-Guard low air loss mattress and settings were determined to be appropriate based on manufacturer's guidelines. On 10/15/2021, the risk, which included entrapment, versus the benefit of side rail use as well as the use of a low air loss mattress was reviewed by RN #1 with Resident #16 and his/her responsible party, and consent was obtained to utilize both devices. Further, Resident #16's alternating low air loss mattress was checked for accuracy of settings/function every shift and documented on the medication/treatment record by the nursing staff. Any concerns identified was immediately reported/addressed by nursing/maintenance. 5. The facility conducted audits and assessments on 10/15/2021 and 10/16/2021 by therapy, nursing and maintenance staff of all side rail utilized in the facility. Residents were screened by therapy and assessed for use per the manufacturer's guidelines to ensure residents' safety. Staff reviewed the side rails to determine the following; medical need for the side rail, accurate assessment completed, specific orders, proof of education regarding the risks/benefits of the side rails, consents for use of the side rails, ensure the care plan and nurse aide Kardex reflected the use of the devices, and proper fit and attachment of the side rails. Any resident identified to benefit for the continued use of side rails was evaluated by therapy staff to ensure appropriate use of the device. 6. On 10/18/2021, the IDT conducted a care plan meeting to complete a comprehensive review of Resident #15 and Resident #16's fall risk, level of necessary supervision, use of assistive devices as applicable, and the resident's current interventions to reduce falls, which included but was not limited to the following items: Brief Interview for Mental Status (BIMs) Score, vision, hearing, medications, labs, and pain. The IDT requested follow up laboratory tests for Resident #15 which included a Prostate Specific Antigen (PSA) and a diagnostic test for a Post Void Residual. The team also requested the resident's physician and psychiatric services review of Resident #15's medications. The IDT reviewed Resident #15's and Resident #16's record weekly during the Falls Meeting for a period of at least four (4) weeks to monitor the efficacy of the fall interventions and revised the interventions as needed. 7. Administrative and direct care staff were trained on the regulatory requirements for F689 and F700 which included definition of an accident, environmental hazards, fall analysis, revision of care plans, root cause analysis, appropriate interventions, resident supervision, fall meetings, side rails and low air loss mattress assessments/consents, risk versus benefits, appropriate alternatives, general safety tips for use of mattresses and appropriate settings and the manufacturer's guidelines for air mattresses utilized in the facility. Further, the training also included licensed staff to monitor and document every shift on the treatment record to indicate air mattresses were on the proper settings. Staff knowledge of training conducted was measured by post-test which required a score of one-hundred (100%) percent. All staff that were not trained by 10/21/2021 were required to complete training and post-tests prior to working next scheduled shift. 8. On 10/20/2021, a Side Rail, Fall Prevention/Resident Supervision, Low Air Loss Mattress Quality Review Audit tool was reviewed/accepted by the Quality Assurance Performance Improvement (QAPI) Committee. The audit tools would be completed five (5) times a week for twelve (12) weeks and results of the audits would be discussed in the monthly QAPI meetings. After the initial twelve (12) week review, a minimum of ten (10) residents would be reviewed monthly for falls. Following the initial twelve (12) week audits conducted related to side rails/air mattresses, audits would continue to be conducted twice (2) monthly for all residents which utilized the devices in the facility. All audits would continue to occur until one-hundred (100%) percent compliance had been determined by the QAPI committee. Any identified concerns would be reported to the QAPI committee and corrective action plans would be developed as needed. A regional team member would also attend QAPI to provide oversight and assist in ensuring compliance, monthly for three (3) months. **The State Survey Agency verified the facility implemented the following corrective actions to remove the Immediate Jeopardy on 10/22/2021 as alleged: 1. Review of Resident #15 and Resident #16's medical record and interview with the Assistant Director of Nursing (DON), on 10/28/2021 at 1:40 PM and Registered Nurse (RN) #1/Unit Manager, on 10/28/2021 at 1:00 PM, revealed on 10/12/2021, Resident #15 and Resident #16 were placed on every fifteen (15) minute checks to increase supervision until the Interdisciplinary Team (IDT) review was completed. Further review and interview with RN #1, on 10/28/2021 at 1:00 PM, revealed she assessed Resident #15 and Resident #16, on 10/13/2021 and no injuries were identified. 2. Review of Resident #15 and Resident #16's medical record and interview with the ADON, on 10/28/2021 at 1:40 PM, and Registered Nurse (RN) #1, on 10/28/2021 at 1:00 PM, revealed on 10/15/2021 at 8:14 PM, an IDT meeting was conducted. Record reviews and continued interviews revealed the IDT team completed a review of Resident #15 related to his/her fall risk, level of necessary supervision, use of assistive devices, which included side rails, and the team also completed a root cause analysis of his/her fall which occurred on 06/02/2021. Further review of the resident's documentation indicated the IDT reviewed the resident's current interventions to reduce falls and the resident's fall related injuries. Documentation in the medical record also revealed the IDT review determined Resident #15 had not fallen in the last ninety (90) days, and staff were to continue every fifteen (15) minute checks during this review. Interview with the ADON, on 10/28/2021 at 8:21 PM, revealed on 10/15/21 the IDT completed a review of Resident #16's fall risk, level of necessary supervision, use of assistive devices which included side rails. Further interview and record review revealed a completed root cause analysis of the fall which occurred on 08/28/2021. Further review/interviews with the ADON and RN #1 confirmed the residents' current interventions to reduce the risk for falls were reviewed and the team determined every fifteen (15) minute checks were to be continued and the residents' care plans were reviewed/revised to indicate the required checks. 3. Review of the facility's audits and interviews with the Assistant Director of Nursing (ADON) at 1:40 PM and Registered Nurse (RN) #1 at 1:00 PM on 10/28/2021, revealed on 10/13/2021, the Director of Nursing (DON) identified residents who had experienced falls within the last thirty (30) days. Continued interviews with the ADON, on 10/28/2021 at 1:40 PM; and the RN #1 at 1:00 PM, revealed the Interdisciplinary Team (IDT) team reviewed the residents' records from 10/13/2021 to 10/21/2021, to ensure fall investigations had been completed appropriately, which included identification of root cause analysis; circumstances which surrounded the falls; falls had been properly tracked/trended and implementation of interventions and preventive measures related to the identified root cause analysis was completed. Further review of the facility's audits and interviews, on 10/28/2021 at 1:40 PM with the ADON; at 1:00 PM with Registered Nurse (RN) #1 (Unit Manager); and at 2:00 PM with the Minimum Data Set (MDS); revealed fall investigations were completed. All identified resident care plans were reviewed to ensure the residents' fall risk were properly care planned which included appropriate level of supervision, the use of assistive devices (side rails and low air loss mattresses), interventions to prevent falls. The residents' responsible party consents were obtained. Continued review of facility's audits and interview with the Assistant Director of Nursing (DON) at 1:40 PM on 10/28/2021, revealed on 10/13/2021, twenty-one (21) residents with orders for low air loss mattresses medical records were reviewed. Further review and interviews indicated the residents' records were reviewed between 10/13/2021 to 10/16/2021, related to risk verses benefit of using a low air loss mattress. Observations and record review, conducted on 10/28/2021 at 1:40 PM confirmed sixteen (16) residents with low air loss mattresses were discontinued based on the review conducted by the Interdisciplinary Team. Further obse [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the baseline care plan was implemented for one (1) of fourteen (14) sampled residents (Resident #5). The facility assessed the resident to require a Hoyer (brand name of a mechanical lift) lift for all transfers due to multiple healing fractures and being unable to bear weight on his/her lower extremities. On 08/25/2021, the facility added the intervention of using the lift with transfers to the resident's base line care plan. On 08/26/2021, the resident fell from his/her bed onto the floor. Facility staff manually lifted the resident from the floor onto the bed instead of using the Hoyer lift. The findings include: Review of the facility's policy titled,Baseline Care Plan Assessment/Comprehensive Care plans, undated, revealed the baseline care plan was intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that were most likely to occur right after admission. Further review revealed upon admission to the facility, the admitting nurse would initiate the baseline care plan assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. Review of the facility's policy titled, Policy and Procedure for Mechanical Lift Transfer Usage, revealed the nursing department would complete an Activities of Daily Living (ADL) assessment to determine the transfer needs of all residents upon admission and quarterly to promote the resident's safety and to maintain their highest practical level of ADL functioning. Further review revealed all residents determined to require a two (2) person transfer would be transferred with the use of a mechanical or sit to stand lift. Review of Resident #5's clinical record revealed the facility admitted the resident, on 08/25/2021, with diagnoses of Fracture of Thoracic Vertebrae, Displaced Bicondylar fracture of Right Tibia, Displaced fracture comminuted of Right Fibula, and Left Calcaneal fracture. Review of Resident #5's hospital Discharge Summary, dated 08/25/2021, revealed the hospital discharged the resident to the facility for rehabilitation. Upon discharge, the resident was assessed as non-weight bearing on bilateral extremities due to healing fractures which resulted from prior trauma related to a tree crushing accident. Review of Resident #5's Baseline Care Plan, dated 08/25/2021, revealed the resident was non-weight bearing and required a Hoyer lift for all transfers. Review of Resident #5's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eight (8). The score of eight (8) which indicated the resident was moderately cognitively impaired. Review of Resident #5's Kardex, (nurse aide care plan) undated, revealed the resident required a Hoyer lift (mechanical lift) for all transfers and was non-weight bearing. Review of the facility's falls incident report for Resident #5, dated 08/26/2021 at 11:59 PM, revealed staff found the resident in his/her room on the floor adjacent to the bed, the resident had a bowel movement, and was confused related to the disease process. Staff assessed the resident to have no new injuries. Continued review revealed staff provided incontinent care and transferred the resident back to his/her bed with three (3) staff assist. Staff failed to follow the resident's Baseline Care Plan. Interview with Licensed Practical Nurse (LPN) #9, on 09/27/2021 at 9:24 PM, revealed she completed the admission assessment and baseline care plan for Resident #5. She stated the resident was non-weight bearing and required a Hoyer lift upon admission for all transfers. She further stated Resident #5 had multiple fractures upon admission and was very confused. Interview with State Registered Nurse Aide (SRNA) #10, on 09/29/2021 at 9:00 PM, revealed she was agency staff and worked at the facility on 08/26/2021 when Resident #5 fell out of his/her bed. The SRNA stated she heard Resident #5 yelling for help, entered the resident's room and found him/her on the floor. Per the SRNA, multiple staff assisted and lifted the resident from the floor back into bed. The SRNA stated she thought Resident #5 was a two (2) person assist and was not aware the resident required a Hoyer lift for transfers. The SRNA stated there was a Kardex (nurse aide care plan) located in each resident's room, which listed the assistance needed and if the resident required a lift. Interview with Registered Nurse (RN) #1, on 09/21/2021 at 1:50 PM, revealed she was working when Resident #5 fell out of his/her bed, on 08/26/2021, but she did not recall the circumstances of the incident. RN #1 stated she recalled Resident #5 was assessed to have a Hoyer lift for transfers. The RN stated staff should have transferred Resident #5 back to bed with a Hoyer lift, as per the resident's care plan. Interview with the Minimum Data Set (MDS) Assessment Nurse, on 10/06/2021 at 11:25 AM, revealed she was responsible for updating the residents' care plans and the Kardex was developed from the care plans. She further stated the admission nurse completed the baseline care plan and the Kardex was updated daily if needed with any changes. Further interview revealed staff should have followed Resident #5's care plan related to transfers. Interview with the Medical Director, on 10/07/2021 at 2:40 PM, revealed he expected facility staff to follow residents' care plans and utilize the Hoyer lifts properly for residents who required lifts. He further stated he expected the facility to provide a safe environment and protect residents from accidents and potential injury. Interview with Director of Nursing (DON), on 10/06/2021 at 5:08 PM, revealed she expected nursing staff to follow the resident's care plan and provide appropriate assistance. The DON stated if a resident required a mechanical lift for transfers and one (1) was not utilized, a resident could be injured. She further stated she expected staff to look at the resident's Kardex before providing care. Per interview, the DON stated that if staff did not utilize the residents' care plans, it could lead to insufficient assistance and incorrect care provided. The DON stated there was no specific orientation or training provided to agency nursing staff prior to them providing resident care. Interview with the Administrator, on 10/06/2021 at 5:55 PM, revealed he expected nursing staff to be oriented to the residents' needs and their level of care before providing care. Per interview, he stated it was his expectation staff would utilize the residents' care plans and Kardex, related to the residents' transfers. He stated this was important to ensure the safety of the residents.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to conduct regular inspections as part of a regular maintenance program, to include all bed frames, mattresses and bed rails to identify the risk of possible entrapment for one (1) of fourteen (14) sampled residents (Resident #14). Record reviews indicated staff placed Resident #16 in a bed with a bed rail designed to assist him/her with bed mobility on 03/18/2020. On 03/28/2020, the facility also placed an alternating pressure relief mattress (a mattress that inflates and deflates) to relieve pressure due to Resident #16's risk for skin breakdown. However, there was no evidence the facility inspected the bed, mattress or the bed rails before they were implemented for use for Resident #16. On 08/28/2021, Resident #16 fell from the bed and the resident's right arm was trapped between the bed rail and mattress. Staff had to remove the mattress from the bed frame, to free Resident #16's upper extremity from entrapment. The facility failed to have a system to ensure bed rails/beds or mattresses were properly maintained to ensure residents were free from the risk of entrapment. The findings include: Review of the facility's policy titled, Side Rails/Enabler Bars not dated, revealed the policy was intended to provide licensed medical staff with a process for the evaluation/documentation needs and interventions that were necessary, related to the evaluation of side rails which were utilized in the facility. According to the policy, side rails should be checked at least quarterly as part of the preventive maintenance program for functionality and loose fit. The policy also stated there must be no more than four and three quarter (4 3/4) inch gap within the rails themselves, or between the rails and any part of the bed frame or the mattress. Review of the facility's policy titled, Preventive Maintenance Program Life Safety Code Documentation last revised on 06/24/2020, revealed inspections conducted monthly by nursing included a complete inspection and measurements of the bed's entrapment zones. The policy also stated any open space between the perimeters of the rail, can present a risk of head entrapment where the recommended space was less than four and three quarter (43/4) inch. The policy also stated a gap between the mattress and the lowermost portion of the rail, posed a risk of neck entrapment with a recommended space of less than 2 and 3/8 inches. Continued review of the policy revealed bed systems compliance audits would be conducted by maintenance staff (no timeframe indicated) which included an inspection of the bed frames, to ensure the mattress fit the bed and, gaps were no larger than four and three fourth (4 3/4) inch between the footboard, headboard and sides. Review of the maintenance compliance audit tool, also indicated electric beds should be assessed for proper functioning; if the footboard/headboard were safe and intact; if the bed had any type of enabler or assist bars; and, if the mattress and support systems were approved by the auditor. However, record review revealed there was no documented evidence the Maintenance Department conducted regular inspections of the residents' bed frames, mattresses, and bed rails, to prevent possible entrapment. Review of Resident #16's medical record revealed the facility admitted the resident on 02/27/2020. The resident's current diagnoses included Acquired Absence of left and right legs below the knee. Review of Resident #16's medical record revealed on 03/18/2020, staff implemented one fourth (1/4) inch bed rails as an enabler to increase his/her independence while he/she was in bed. Further review of Resident #16's record revealed, on 03/28/2020, staff also placed an alternating pressure relief mattress (a mattress that inflates and deflates) to relieve pressure due to the resident's risk of skin breakdown. Review of Resident #16's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Observations of measurements of the gap between Resident #16's side rail and air mattress, conducted by Maintenance Staff #2, on 10/12/2021 at 3:05 PM, revealed there was a three quarter (3/4) inch opening between the two (2) devices. Interview with Resident #16, on 09/30/2021 at 11:30 AM, revealed he/she used the side rails for bed mobility. Further interview revealed on DATE, the resident dropped his/her cell phone on the floor and when he/she leaned over to retrieve his/her phone, he/she fell out of the bed. Per interview, his/her right arm got stuck in the side rail and mattress and staff had to take the mattress from the bed, to remove his/her arm out of the side rails. Interview with Maintenance Staff #2, on 10/12/2021 at 2:55 PM, revealed the facility had no system in place to provide ongoing monitoring to ensure maintenance of residents' beds, bed frames, bed rails or mattresses. Continued interview revealed the facility did not have measurements of the gaps between the bed frames/bed rails/mattresses. The staff stated measurements were not regularly obtained to ensure requirements regarding entrapment zones (an area where an individual can get their their head, neck, chest or other body parts caught in the tight space around the bed rail or bedside mobility aide) were evaluated/inspected regularly by maintenance. Interview with the Maintenance Director, on 10/05/2021 at 11:35 AM, revealed he, nor maintenance staff were directed to conduct regular inspections of bed rails, bed frames, and/or mattresses as part of the maintenance program to identify areas of possible entrapment. Interview with the Director of Nursing (DON), on 10/06/2021 at 1:55 PM, revealed the nursing department had not conducted measurements or any ongoing evaluations of beds, bed rails or mattresses utilized in the facility. According to the DON, the use of side rails, or mattresses which included the use of air mattresses, did not pose any risks to the residents. Interview with the Administrator, on 10/06/2021 at 1:50 PM, revealed he was unaware the facility had no system to ensure safe use of bed rails, beds and mattresses. However, he stated it would have been his expectation that the maintenance department would conduct measurements of the residents' beds, bed rails and mattresses to ensure the devices were utilized safely regarding entrapment zones, for the safety of the residents.

Based on observation, interview, record review, and review of the facility's policies it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of three (3) sampled residents (Resident #1). Observation of wound care for Resident #1 on 07/08/2021 revealed Licensed Practical Nurse (LPN) #1 performed wound care without establishing a clean barrier to prevent contamination of the wound. In addition, LPN #1 dropped a bandage into a heel boot and then used the bandage for wound care. The findings include: Review of the facility's policy titled Skin Weight Assessment Team (SWAT) Program, not dated, revealed the facility would aggressively review and address residents that exhibited skin breakdown. Those residents would be monitored on a weekly basis. The policy stated that once wound care was initiated, trained nursing staff would perform treatments using infection control techniques. Interview with the Administrator on 07/08/2021 at 12:20 PM revealed the facility did not have a policy that addressed the steps in performing wound care. Review of Resident #1's medical record revealed the facility readmitted the resident on 07/02/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have severe cognitive impairment. The MDS assessment stated that the resident was admitted to the facility with Diabetic Foot Ulcers that required application of dressings to the feet. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of wound care on 07/08/2021 at 10:16 AM revealed LPN #1 performed wound care to Resident #1's bilateral feet while the resident's feet were resting on top of his/her heel boots. LPN #1 failed to place a clean barrier under the resident's feet prior to performing wound care. She cleansed Resident #1's right heel with wound cleanser and painted the affected area with [MEDICATION(S)] and then sat the resident's right heel down on top of his/her heel boot before covering the area with an ABD pad and wrapping with Kerlix. Further observation of wound care revealed LPN #1 cleansed the outer aspect of Resident #1's right foot with wound cleanser and dropped the Maxsorb ag dressing onto the heel boot and proceeded to pick the dressing up off the heel boot and place it on the wound. Interview with LPN #1 on 07/08/2021 at 3:16 PM revealed she was trained to perform wound care on a clean barrier. She stated she should not have performed wound care on top of the resident's heel boots due to increased chance of infection. She further stated when she dropped the Maxsorb ag dressing in the heel boot, she should have disposed of the dressing and got a new dressing instead of placing the contaminated dressing onto the resident's right outer foot wound. Interview with the Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP) on 07/09/2021 at 1:49 PM revealed she expected staff to perform wound care utilizing infection control practices. She stated LPN #1 should have provided a clean barrier to perform wound care on and she should have disposed of the contaminated dressing and obtained a new dressing. No interview was performed with the Director of Nursing (DON) because she was on medical leave due to a surgical procedure. Interview with the Administrator, on 07/09/2021 at 2:19 PM, revealed he expected staff to perform wound care following infection control standards. He stated wound care should be performed on a clean surface and supplies utilized should not be contaminated.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to inform the physician when a change in condition occurred for one (1) of one (1) sampled residents (Resident #11). Resident #11 sustained two (2) falls after admission to the facility in March 2021 and developed new bruising to the right side, right inner knee, right thigh, left knee and left outer thigh. In addition, the resident developed new pain to his/her legs/knees which was not relieved by the current ordered pain medication. However, the facility failed to notify the resident's physician of changes in the resident's condition (new bruising and new complaints of pain). The findings include: Review of the facility's policy, Change in a Resident Condition or Status, undated, revealed staff would notify the resident's physician and representative of significant changes in the resident's medical, mental or psychological status. Further review of the policy revealed a significant change in condition is a decline or improvement in the resident's status will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan. The policy stated the nurse will notify the resident's attending physician when the resident is involved in any accident or incident that resulted in injury including injuries of unknown origin. Review of a closed record for Resident #11 revealed the facility admitted the resident on 03/09/2021 with diagnoses which included Alzheimer's, Dementia, Type 2 Diabetes Mellitus, Nondisplaced Fracture of Surgical Neck of Left Humerus, Unspecified Pain, Neuropathy and Nutritional Anemia. A review of the Admission Minimum Data (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was assessed to have severe impaired cognition. Further review of the MDS revealed the resident required set-up assistance with supervision for eating. Review of the MDS revealed no skin breakdown. Per the MDS, Resident #11 voiced he/she had frequent pain or was hurting in the last five (5) days at a rate of five (5) on a scale of zero (0) to ten (10) with zero (0) being no pain and ten (10) being the worst pain you can imagine. The facility coded Resident #11 had received as needed (PRN) pain medication or was offered but declined the medication during the last five (5) days. Per the MDS, Resident #11 had a history of falling during the last month and during the last two (2) to six (6) months. Further review revealed the resident had sustained a fracture related to a fall in the last six (6) months prior to admission/entry or reentry to the facility. A review of the admission skin assessment completed on 03/09/2021 at 6:19 PM revealed Resident #11 had bruising to the back of the right hand. However, no other bruising was noted on the skin assessment. A review of Resident #11 Physician Orders revealed he/she was ordered Hydrocodone-Acetaminophen 7.5-325 milligrams (mg) every four (4) hours as needed for pain for the left humerus fracture. 1). Review of medical record revealed on 03/18/2021 at 8:46 AM, Resident #11 sustained a fall. Documentation of the fall by Licensed Practical Nurse (LPN) #2 revealed Resident #11 stated his/her knees were starting to hurt when asked if she was in pain during post fall assessment. Continued review revealed the resident had no new areas of bruising noted (bruise to right knee from fall prior to admission to the facility). Medical Doctor #1 was notified at 8:51 AM. Continue review revealed on 03/18/2021 at 12:26 PM, LPN #2 documented Resident #11 had bruising to left outer thigh related to the fall. However, there was no evidence the medical doctor was notified with the new injury of bruising to the left outer thigh. Continued review of medical record revealed on 03/21/2021 at 4:09 AM, Resident #11 sustained a second fall at the facility. Upon assessment, the resident was found to have no apparent injuries. Review of record revealed Medical Doctor #1 was notified of the fall at 6:00 AM. Review of medical record revealed on 03/22/2021 at 1:12 PM, LPN #2 documented in Resident #11's progress note, the resident was observed to have bruising to the right side, right inner knee, right thigh, left knee and left outer thigh. However, again there was no evidence the medical doctor was notified of the bruising secondary to prior fall. Interview with LPN #2, on 04/28/2021 at 12:35 PM and 05/10/2021 at 5:48 PM, revealed Resident #11 did have bruising to the left outer thigh related to the fall. However, she was unable to recall if she notified the medical doctor regarding the bruising. Further interview revealed on 03/22/2021 at 11:04 AM, the resident had bruising to the right side, right inner knee, right thigh, left knee and left outer thigh. LPN #2 stated she was did not recall if she notified the medical doctor or any other staff of the bruising. Interview with the Assistant Director of Nursing (ADON), at 05/10/2021 at 6:44 PM, revealed new findings related to falls should have been reported (bruising, etc.). Interview with the Director of Nursing (DON), on 05/12/2021 at 12:17 PM, revealed if a resident falls some bruising is expected. However, if the bruise was significant in size then the physician should be notified. Interview with Nurse Practitioner (NP) #1, on 05/10/2021 at 7:06 PM, revealed she evaluated Resident #11 on 03/18/2021 at 5:17 PM. Per the NP, she was aware of the fall; however, she had been informed the fall was witnessed with no mention of any bruising. Interview with NP #2, on 05/11/2021 at 4:30 PM, revealed she visits the facility five (5) days a week. The NP stated she evaluated Resident #11 on 03/19/2021 related to Anxiety, Dementia with Behavioral Disturbances and Depression. She further revealed she was not notified Resident #11 sustained a fall on 03/18/2021 or about the resident having bruising. Interview with NP #3, on 05/13/2021 at 11:10 AM, revealed she completed a visit with Resident #11 on 03/22/2021; however, she was not informed by facility staff the resident had sustained a fall on 03/21/2021. Interview with Medical Doctor #1, on 05/11/2021 at 12:57 PM, revealed he was made aware of the two (2) falls Resident #11 sustained while at the facility. However, was unable to recall notification of the bruising on Resident #11. He further revealed if a resident had a change in condition (like bruises), he would expect to be notified. 2). Review of medical record Pain Review on 03/09/2021 at 6:23 PM, revealed Registered Nurse (RN) #1 assessed Resident #11's pain and documented the resident rated his/her pain at a rate of 4 on the numeric scale of zero (0) to ten (10). Per the assessment, the resident reported the pain location as left upper extremity related to a broken humerus. The assessment revealed the pain lasted until medication was administered and the pain had begun on 02/17/2021. However, was alleviated with medication. Review of the nurse's notes revealed on 03/18/2021 at 8:46 AM, Resident #11 sustained a fall. Documentation of the fall by Licensed Practical Nurse (LPN) #2 revealed Resident #11 stated his/her knees were starting to hurt when asked if he/she was in pain during the post fall assessment. Review of Medication Administration Record (MAR) on 03/18/2021 at 10:07 PM, revealed Resident #11 voiced complaints of pain at a rating of five (5). Resident #11 received Hydrocodone-Acetaminophen 7.5-325 milligrams (mg) for pain. However, further review of the MAR revealed the medication was charted as ineffective. Continued review of MAR revealed Resident #11 was assessed to have pain at a rating of five (5) on 03/18/201 at 10:07 PM. and again, Resident #11 was received Hydrocodone-Acetaminophen 7.5-325 milligrams (mg) for pain. However, again staff documented the medication was ineffective. On 03/20/2021 at 7:41 PM, Resident #11 voiced pain in his/her legs. Review of the MAR for March 2021 revealed on 03/20/2021 at 6:30 PM, Resident #11 rated his/her pain at a level of 8. Resident #11 received Hydrocodone-Acetaminophen 7.5-325 milligrams (mg) for pain. However, review of the MAR further revealed the medication was charted as ineffective by LPN #3. On 03/21/2021 at 12:18 AM, staff documented Resident #11 was yelling out about wanting to die, screaming make me die and All I want to is die die die!. Further review of documentation revealed Resident #11 had complaints of pain to his/her legs. Review of MAR revealed Resident #11 was administered Hydrocodone-Acetaminophen 7.5-325 mg for pain at 12:32 AM which was documented as effective. However, at 1:03 AM and 3:28 AM on 03/21/2021, staff documented Resident #11 was screaming and/or yelling. Further review of the record revealed no evidence the Medical Doctor was notified the pain medication was ineffective to treat Resident #11's pain. Furthermore, there was no evidence the staff notified the Medical Doctor the resident was voicing new complaints of pain in his/her legs. Interview with LPN #2, on 04/28/2021 at 12:35 PM and 05/10/2021 at 5:48 PM, revealed on 03/18/2021, the resident complained of pain when her arm sling was on. However, was unable to recall any further pain. Interview with LPN #3, on 05/11/2021 at 2:35 PM, revealed she provided care for Resident #11 on 03/20/2021 from 7:00 AM to 7:00 PM. The LPN stated she did recall Resident #11 complaining of leg pain. The LPN stated when she would provide care the resident would moan more and complain of leg pain. Per the LPN, she administered pain medication to Resident #11. However, she continued to scream anytime the staff was not in the room with her. The LPN stated she notified the Assistant Director of Nursing (ADON) of Resident #11's leg pain in evening report during shift change at approximately 7:00-8:00 PM. Interview with the ADON, at 05/10/2021 at 6:44 PM and 05/11/2021 at 4:00 PM, revealed on 03/20/2021 she was required to work the floor. The ADON stated LPN #3 gave her report regarding Resident #11 and the LPN #3 reported every now and then when the resident would move, he/she would complain of leg pain. However, the pain in his/her arm had not changed. Further interview revealed if the leg pain was new, the physician should have been notified. Interview with the Director of Nursing (DON), on 05/12/2021 at 12:17 PM, revealed it was her understanding Resident #11 had frequent complaints of pain. Therefore, she would not have considered the leg pain as new. Interview with NP #2, on 05/11/2021 at 4:30 PM, revealed she visits the facility five (5) days a week. The NP stated she evaluated Resident #11 on 03/19/2021 related to Anxiety, Dementia with Behavioral Disturbances and Depression. She further revealed she was not notified Resident #11 sustained a fall on 03/18/2021 or about the resident having pain in his/her legs. Interview with Medical Doctor #1, on 05/11/2021 at 12:57 PM, revealed he was made aware of the two (2) falls Resident #11 sustained while at the facility. However, was unable to recall if he was notified of the new complaints of leg pain. He further revealed he expects staff to notify him of changes in resident condition including complaints of pain. MD #1 stated if he was aware of the complaints of pain, he would have ordered an x-ray of the area. He continued, if the resident still had complaints of pain after a negative x-ray, he would have ordered a CT scan of the area.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of one (1) sampled residents (Resident #11) when the resident exhibited behaviors of continuously trying to get out of bed on 03/15/2021. The resident sustained two (2) falls, on 03/18/2021 and on 03/21/2021, which was a result of the resident attempting to get out of bed. The findings include: Review of the facility policy titled Baseline Care Plan Assessment/Comprehensive Care Plans, undated, revealed the comprehensive care plan would expand on the resident's medical, nursing, physical functioning, mental, and psychosocial needs. Staff would develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. Further, the care plan would be reviewed and updated every quarter at a minimum, and more often based on changes in the resident's condition and/or newly developed health/psycho-social issues. According to the policy, the Minimum Data Set (MDS) Assessment/Care Plan Coordinator and/or ancillary MDS staff would participate in daily meetings to review and discuss new or changed orders, new admissions, readmissions, falls, and other pertinent circumstances regarding the resident and revise/update the care plans as necessary. Review of a closed record for Resident #11 revealed the facility admitted the resident on 03/09/2021 with diagnoses which included Alzheimer's, Dementia, Type 2 Diabetes Mellitus, Nondisplaced Fracture of Surgical Neck of Left Humerus, Unspecified Pain, Neuropathy, and Nutritional Anemia. Review of the hospital documentation for 03/09/2021, prior to Resident #11's transfer to the facility, revealed hospital staff documented that the patient had a history of getting up and falling repeatedly. The facility developed a baseline care plan, on 03/10/2021 that identified the resident had a history of falls. According to the care plan, the facility developed an intervention to provide one (1) to one (1) supervision for Resident #11. Interview with State Registered Nurse Aide (SRNA) #3 on 05/11/2021 at 3:45 PM revealed the resident continuously tried to get out of bed. According to the SRNA, the resident had a sitter the first night because they were told he/she was at high risk for falls. However, after the first night, she or a nurse tried to sit with the resident to keep him/her from falling. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident exhibited verbal and other behavioral symptoms daily. Review of progress notes revealed on 03/15/2021 at 1:06 AM, Resident #11 was continuously trying to get out of bed. Staff attempted multiple times to redirect and calm the resident with no success. However, further review of care plan revealed the facility failed to revise or update the resident's plan of care to address the resident continuously trying to get out of bed or implement interventions to achieve the greatest degree of safety. Review of Resident #11's medical record revealed on 03/18/2021 at 8:46 AM, staff heard a bed alarm sounding. When staff entered Resident #11's room, he/she was found on his/her hands/knees at the bedside. Resident #11 revealed he/she wanted to get up so he/she got down in the floor. The facility implemented a fall mat to the floor; however, did not address the resident's attempts to get out of bed unassisted. Interview with Licensed Practical Nurse (LPN) #2 on 04/28/2021 at 12:35 PM revealed she found the resident on the floor. The resident told the LPN that he/she was trying to get up and slid out of bed. Review of the comprehensive care plan dated 03/20/2021 revealed the facility identified that Resident #11 had potential for serious injury/fall related to attempt to self-transfer and sit on the floor (non-injury). The facility developed interventions that included a bed alarm and a fall mat (initiated on 03/18/2021 after the resident fell ). Interview with LPN #3 on 05/11/2021 at 2:35 PM, revealed she provided care for Resident #11 and one other resident on the COVID unit on 03/20/2021 during the day shift. She stated she had to stay in Resident #11's room, because if the resident could not see her, the resident would try to get out of bed. LPN #3 stated she had to leave Resident #11's room at times to check on the other resident, and stated she went fast because she was afraid Resident #11 would fall. According to LPN #3, the ADON relieved her on 03/20/2021 and she told the ADON that the resident had been trying [his/her] best to get out of bed. Continued review of Resident #11's progress notes revealed on 03/21/2021 at 12:18 AM, the resident had to be repositioned several times. Further review revealed at 4:09 AM on 03/21/2021, the nurse left the resident for about one minute to check on the other resident when she heard Resident #11's alarm sounding. When staff arrived to Resident #11's room, he/she was on his/her knees on the floor mat. The facility implemented a body pillow to the exit side of the resident's bed, but did not address the resident's attempts to get out of bed unassisted. Continued review of Resident #11's progress notes revealed on 03/21/2021 at 2:22 PM, LPN #1 documented that the resident has attempted to climb out of bed multiple times. Writer has spent majority of this shift one on one with patient. Interview with LPN #1 on 05/06/2021 at 6:04 PM revealed she tried to stay in Resident #11's room so the resident would not climb out of bed. However, there was no documented evidence that the facility revised the resident's care plan to ensure the resident was supervised. Further review of Resident #11's progress notes revealed on 03/22/2021 at 9:00 AM, LPN #2 documented that the resident's alarm was sounding and when she went into room resident was attempting to get up out of bed. Again, there was no documented evidence the facility revised the resident's care plan to ensure the resident was supervised to prevent accidents. A post exit interview with the MDS Coordinator on 05/27/2021 at 12:51 PM, revealed if a resident had a change in condition, including falls, behaviors (trying to get out of bed), etc., the care plan should have been revised. According to the MDS Coordinator, behaviors should be discussed during morning meetings, and then she would revise the baseline care plan or the comprehensive care plan.

Based on interview, record review, and a review of the facility policy, it was determined the facility failed to immediately inform the physician and the responsible party when a change in condition occurred for one (1) of three (3) sampled residents (Resident #1). According to a staff member, purple bruising was observed from Resident #1's left wrist down to his/her pinky finger (fifth digit) on 09/02/19. State Registered Nurse Aide (SRNA) #1 reported the change in Resident #1's condition to Licensed Practical Nurse (LPN) #1 on 09/02/19. However, the facility failed to ensure Resident #1's physician and responsible party were notified of the resident's injury. The resident's responsible party was not aware of the injury until 09/04/19, when she visited the resident and discovered the injury for herself. Further, the facility failed to notify the resident's physician until the responsible party brought the injury to staff's attention on 09/04/19, two days after the injury was initially discovered. Resident #1's physician ordered an x-ray on 09/04/19 and determined that the resident had an acute non-displaced fracture of his/her fifth metacarpal (pinky finger) to his/her left hand. The findings include: Review of the facility policy titled Change in Resident Condition or Status, not dated, revealed the facility was required to ensure the resident's physician and his/her representative were notified when changes in the resident's condition occur. The policy also stated staff were required to notify the resident's physician and his/her representative when an accident/incident, which included injuries of unknown origin, occurred for facility residents. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his/her admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident required extensive assistance of two (2) staff members for transfers, bed mobility, and toileting. Resident #1's MDS also revealed the resident had a brief interview for mental status (BIMS) score of 00, which indicated the resident was not interviewable. Review of Resident #1's nurse's notes dated 09/04/19 at 11:59 PM revealed staff implemented an intervention to monitor the resident due to bruising and [MEDICAL CONDITION] to the resident's left outer hand. Interview with SRNA #1 on 09/12/19 at 10:00 PM revealed she provided care for Resident #1 on 09/02/19 and 09/03/19. She stated she initially observed bruising to the resident's hand on 09/02/19. She stated Resident #1 had [MEDICAL CONDITION] and purple bluish bruising to the left hand that extended from the resident's wrist down to his/her pinky finger (fifth digit). SRNA #1 stated she immediately reported the change in the resident's condition to Licensed Practical Nurse (LPN) #1 on 09/02/19. Interview with LPN #1 on 09/13/19 at 10:30 AM revealed he cared for Resident #1 on 09/02/19 and 09/03/19. He stated that SRNA #1 reported bruising to Resident #1's left hand on 09/02/19, and he observed purple bruising to Resident #1's left pinky finger (fifth digit) on 09/02/19. The LPN stated he had the resident to squeeze his hand; however, he acknowledged that he did not further assess the resident's hand or identify the [MEDICAL CONDITION] present to the resident's hand. The LPN stated he had been trained and was aware that he was required to report injuries of unknown origin immediately to the resident's physician and their representative; however, he stated it slipped his mind and he did not notify Resident #1's physician or representative as required by facility policy. Interview with LPN #2 on 09/13/19 at 10:00 AM revealed she was providing care to Resident #1 on 09/04/19, when the resident's family member asked the LPN what happened to the resident's hand. LPN #2 stated she was not aware the resident had an injury to the hand, but discovered the resident's left hand was swollen and had faded blue bruising to the pinky finger (fifth digit). LPN #2 stated she notified the resident's physician of the injury and an order for [REDACTED].>Review of Resident #1's mobile x-ray report dated 09/04/19 revealed the resident was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed staff should have reported the bruising to Resident #1's left hand immediately to her, the resident's physician, and the resident's representative on 09/02/19 as directed in the facility policy. Interview with the Administrator on 09/13/19 at 4:30 PM revealed staff had been trained to report changes in the resident's condition immediately as outlined in the facility policy. The Administrator also stated that LPN #1 should have reported Resident #1's bruising to her, the resident's representative, and the resident's physician when the injury was identified on 09/02/19. A post-survey interview with Physician #1 on 09/16/19 at 2:00 PM revealed he expected staff to follow their policy and procedures when changes in a resident's condition were identified. Interview with LPN #2 on 09/13/19 at 10:00 AM revealed she provided care to Resident #1 on 09/04/19, but was unaware that the resident had an injury to his/her hand and had not assessed the resident's hand. LPN #2 stated she was not aware of the resident's injury until the resident's daughter asked her what happened to Resident #1's hand on 09/04/19. LPN #2 stated Resident #1's left hand was swollen in appearance and bruising, faded blue in color, was observed to his/her pinky finger (fifth digit). The LPN stated she had been trained to conduct a head-to-toe assessment of residents when bruising, especially with [MEDICAL CONDITION], was identified. In addition, she stated an incident report should have been completed, and ongoing monitoring should have been implemented to assess the resident every shift for the following seventy-two (72) hours. Continued interview with LPN #2 revealed she notified Resident #1's physician of the injury to Resident #1's hand on 09/04/19, and an order for [REDACTED].>Review of a skin assessment dated [DATE] completed by Unit Manager (UM) #1 revealed Resident #1 had light purplish coloring with mild [MEDICAL CONDITION] to left pinky and outer hand. However, review of photographs taken by Resident #1's POA on 09/04/19 revealed [MEDICAL CONDITION] and light purple/brown bruising was observed to the lateral aspect of his/her left wrist, extending to the middle of the resident's fifth digit. The photographs also revealed bruising, blue in color, was observed inside the resident's palm and the front aspect of the resident's fifth finger. Light brown/purple bruising was also observed to the resident's left hand/knuckle area. Review of Resident #1's physician orders dated 09/04/19 at 2:58 PM revealed Physician #1 directed staff to do a stat x-ray of the resident's left hand due to bruising and [MEDICAL CONDITION]. Review of Resident #1's mobile x-ray report dated 09/04/19 of his/her left hand revealed Resident #1 was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed LPN #1 should have completed an assessment of Resident #1 when the bruising was observed to his/her left hand on 09/02/19, should have informed the oncoming shift of the injury, and should have implemented ongoing monitoring for seventy-two (72) hours to ensure the resident's condition was assessed. A post-survey interview with Physician #1 conducted on 09/16/19 at 2:00 PM revealed the physician expected staff to follow their policy and procedures when changes in a resident's condition occurred, which included bruising.

Based on interview, record review, review of a facility investigation, and review of the facility policy, it was determined the facility failed to develop and implement a person-centered care plan for one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was always incontinent of bowel/bladder and required extensive assistance of two (2) staff members for bed mobility and toileting. However, review of the resident's care plan revealed the facility developed a care plan that stated the resident required one (1) to two (2) staff persons. Interviews with staff revealed even though the resident was combative with care, only one (1) staff member assisted the resident with incontinence care. In addition, interviews with staff and review of a facility investigation revealed Resident #1 exhibited behaviors (flailing his/her arms and hitting/grabbing staff and/or bed rails) when staff provided care for the resident. However, the facility failed to implement interventions to address the behavior/prevent resident injury. On 09/02/19, staff discovered bruising and [MEDICAL CONDITION] to Resident #1's left hand. On 09/04/19, the resident was diagnosed with [REDACTED]. The findings include: Review of the facility policy titled Baseline Care Plan Assessment/Comprehensive Care Plans, last reviewed 09/18/18, revealed the Comprehensive Care Plan would expand on the resident's risks, goals, and interventions using the Person-Centered Plan of Care approach for each resident. According to the policy, the care plan was required to include measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. Residents' needs would be determined from observation, interviews, clinical medical record review, and through review of the resident's MDS assessment. According to the policy, the facility interdisciplinary team was required to discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. Review of Resident #1's medical record revealed the facility admitted the resident on 08/03/19 with [DIAGNOSES REDACTED]. A review of Resident #1's admission MDS dated [DATE] revealed the resident was always incontinent of bowel and bladder and required extensive assistance of two (2) staff members for bed mobility and toileting. According to the MDS, the resident was not interviewable due to impaired cognition and did not exhibit any maladaptive behaviors. Review of Resident #1's comprehensive care plan dated 08/16/19 revealed staff identified that the resident had altered ability to perform activities of daily living related to cognitive loss and decreased mobility. The care plan also indicated that the resident was at risk for serious injury related to the use of side rails, cognitive loss, and decreased safety awareness. The facility developed an intervention for one (1) or two (2) staff members to assist the resident with bed mobility and incontinence care. Further review of Resident #1's care plan revealed the resident had a history of [REDACTED]. Again, the facility's plan to address the mood/behavior was for one (1) or two (2) staff members to provide incontinence care and bed mobility for the resident. Interventions also included promoting and cueing the resident as needed, observing for any changes in condition, and reporting changes in the resident's mood status to the physician. Review of Resident #1's State Registered Nurse Aide (SRNA) Kardex, not dated, directed one (1) or two (2) to assist the resident with all transfers and bed mobility. Review of a facility investigation revealed Resident #1 was observed to have a bruise to his/her left fifth finger on 09/02/19, and was diagnosed with [REDACTED]. According to the investigation, numerous staff members reported that Resident #1 was combative with care. Staff statements also revealed that at times the resident slings his/her arms around when he/she became anxious, moving his/her arms through the air striking at things. Licensed Practical Nurse (LPN) #1's statement revealed that when the bruise was identified he was sure the resident bumped it on the table or side rails of the bed and an SRNA had informed the LPN that the resident is active and has a strong grip. However, continued review of Resident #1's care plan and Kardex revealed no documented evidence that the facility had identified the resident's behavior of slinging/striking things nor developed interventions to address the behavior. Interview with SRNA #1 on 09/12/19 at 10:00 PM revealed Resident #1 was confused and combative most of the time and yelled out when incontinence was provided. She also stated the resident grabbed the bed rail, and would hit them while flailing his/her arms during incontinence care. Even though the SRNA stated the resident had multiple behaviors when care was provided, she provided care to the resident alone, without the assistance of another staff member. SRNA #1 stated she had reported the resident's behaviors to licensed nurses at the facility, including Licensed Practical Nurse (LPN) #1. Interview with SRNA #2 on 09/12/19 at 10:15 PM revealed he cared for Resident #1 and stated the resident would get a death grip on the bed rail when providing care for the resident. The SRNA also stated the resident would grab staff's arms. SRNA #2 stated it was very difficult for one (1) staff person to care for the resident when he/she was in bed, but stated he provided care to the resident by himself because the Kardex directed one (1) or two (2) to provide care. SRNA #2 stated he had reported the resident's combative behavior to facility nurses; however, he was unaware of any interventions that were implemented to prevent Resident #1 from harming him/herself when care was provided. Interview with SRNA #3 on 09/12/19 at 10:30 PM revealed she provided care for Resident #1 without the assistance of another staff member. According to the SRNA, the resident had combative behaviors that were worse when (the resident) was getting changed (incontinence care). The SRNA stated the resident yelled out, would shake and grab his/her bed rails, and would hit them sometimes due to the resident flailing his/her arms when care was provided. She stated she had reported the resident's behaviors to nurses; however, she was unaware of any interventions that had been implemented to protect the resident from injury due to his/her behaviors. Interview with LPN #1 on 09/13/19 at 10:30 AM confirmed that staff had reported that Resident #1 had combative behaviors. The LPN stated he observed Resident #1 be up against his/her bed rails and grabbing staff/bed rails when care was provided. LPN #1 stated, We don't document behaviors, and stated he had not been trained to document combative behaviors exhibited by residents in the facility. However, the LPN acknowledged if interventions had been implemented related to the resident's combative behaviors, the resident's diagnosed fracture on 09/04/19 could have possibly been prevented. Interview with LPN #2 on 09/13/19 at 10:00 AM revealed she was aware that Resident #1 was combative when care was provided and that the resident flailed his/her arms hitting the side rails at times. LPN #2 stated she thought Resident #1 exhibited the behavior because he/she was confused and afraid when staff provided care. LPN #2 stated she had not documented/reported the resident's behavior because there was no process in place to document resident behavior. The LPN stated Resident #1's behaviors should have been reported to the MDS nurse, the facility Social Worker, and/or the Director of Nursing (DON) so interventions could have been implemented to prevent potential injury to the resident. According to the LPN, on 09/04/19 Resident #1's daughter reported that the resident had bruising and [MEDICAL CONDITION] to his/her left hand. She stated she notified the resident's physician and an order for [REDACTED].>Review of photographs of Resident #1's left hand taken by Resident #1's POA on 09/04/19 revealed Resident #1 had [MEDICAL CONDITION] and light purple/brown bruising to the lateral aspect of his/her left wrist, extending to the middle of the resident's fifth digit. Further review of photographs revealed bruising, blue in color, was observed inside the resident's palm and the front aspect of the resident's fifth finger. The resident's left hand/knuckle area was also observed to have light brown/purple bruising. Review of Resident #1's mobile x-ray report dated 09/04/19 of the resident's left hand, revealed Resident #1 was diagnosed with [REDACTED]. Interview with the facility Social Worker (SW) on 09/13/19 at 2:15 PM revealed, We knew Resident #1 had behaviors. We were told that from where (the resident) came from. However, the SW then stated she was not aware nor had any one reported that Resident #1 was combative during care. She stated that had she known, she would have discussed the resident's behavior with the clinical team and ensured interventions were implemented, such as padded side rails or something was in place to ensure Resident #1's safety. Interview with the MDS Coordinator on 09/13/19 at 1:15 PM revealed she coded MDS assessments based on information documented in the resident's medical record. She stated staff had not documented nor notified her that Resident #1 exhibited behaviors; however, she stated those behaviors should have been care planned and interventions implemented as appropriate. She stated even though she coded that Resident #1 required extensive assistance of two (2) staff members with bed mobility, she developed a care plan that stated that the resident required one (1) to two (2) staff members to assist the resident because she expected the nurse aides to determine the level of assistance needed at the bedside. Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed she was aware that Resident #1 would sling his/her arms and stated, Some felt it was combative, and some felt it was dementia. However, she stated Resident #1's behaviors had not been discussed within the clinical team and acknowledged a care plan with interventions had not been implemented for the resident. Further interview with the DON revealed nurse aides should not assess residents to determine the level of assistance needed when care was provided. She stated if the resident's behavior had been discussed, staff could have identified that the resident required two (2) staff members to assist when care was provided, as indicated by the MDS assessment. Interview with the Administrator on 09/13/19 at 4:30 PM revealed she was not accustomed to seeing one (1) to two (2) staff assist on a care plan. The Administrator stated nurse aides could determine what level of assistance a resident needed, according to the resident's mood at the time care was provided. However, the Administrator acknowledged unlicensed staff was not trained to assess residents to determine safety needs. The Administrator also stated that even though the investigation revealed the resident had behaviors when care was provided, the facility had not reviewed/revised the resident's care plan and/or implemented interventions related to the resident's identified behaviors.

Based on interview, record review, and a review of facility policy, it was determined the facility failed to provide needed care and services when a change in condition occurred for one (1) of three (3) sampled residents (Resident #1). Interviews revealed [MEDICAL CONDITION] and bruising were observed to Resident #1's left hand on 09/02/19. However, staff failed to assess the resident and failed to notify the resident's physician of the resident's change in condition. On 09/04/19, the resident's family visited and discovered the resident's injury and requested an x-ray. The facility obtained a physician's order for the x-ray and documented that Resident #1 had light purplish coloring with mild [MEDICAL CONDITION] to left pinky and outer hand. However, review of photographs taken by Resident #1's POA on 09/04/19 revealed [MEDICAL CONDITION] and bruising to the lateral aspect of the resident's left wrist, extending to the middle of the resident's fifth digit; bruising to the palm and the front aspect of the resident's fifth finger; and bruising to the left hand/knuckle area. Resident #1 was diagnosed with [REDACTED]. The findings include: Review of the facility policy titled Assessment, dated (MONTH) (YEAR), revealed staff were required to complete an assessment of residents when a significant change in his/her condition occurred, or when an event took place, which required an assessment by qualified medical personnel. Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed when a change in condition occurred, staff should notify the oncoming shift and implement ongoing monitoring for seventy-two (72) hours to ensure the resident's condition was assessed. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his/her admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident required extensive assistance of two (2) staff members for transfers, bed mobility, and toileting. Resident #1's MDS also revealed the resident had a brief interview for mental status (BIMS) score of 00, which indicated the resident was not interviewable. Interview with State Registered Nurse Aide (SRNA) #1 on 09/12/19 at 10:00 PM revealed she observed [MEDICAL CONDITION] and purple bluish bruising to the resident's left hand that extended from Resident #1's wrist down to his/her pinky finger (fifth digit) on 09/02/19. SRNA #1 stated she immediately reported the change in the resident's condition to Licensed Practical (LPN) #1. Continued interview with SRNA #1 revealed she also provided care for Resident #1 on 09/03/19. Continued review of Resident #1's medical record revealed no documented evidence that LPN #1, or any other facility staff member, assessed Resident #1's left hand on 09/02/19 or 09/03/19. Interview with LPN #1 on 09/13/19 at 10:30 AM revealed he cared for Resident #1 on 09/02/19 and 09/03/19. The LPN confirmed that SRNA #1 reported bruising to Resident #1's left hand on 09/02/19, and he observed purple bruising to Resident #1's left pinky finger (fifth digit) on 09/02/19. The LPN stated he had the resident to squeeze his hand; however, he acknowledged that he had not identified the [MEDICAL CONDITION] present to the resident's hand. The LPN also stated he should have completed a change in condition form, which would have required him to complete a head-to-toe assessment of the resident when the change in condition was identified. The LPN also stated he should have documented the change in the resident's condition in his/her medical record, and implemented ongoing monitoring for the following seventy-two (72) hours after the bruising was identified, because that was the process in the facility. LPN #1 also stated he should have also informed the oncoming shift of the change in the resident's condition. The LPN also stated it slipped his mind and he failed to follow the facility policy/protocols as required. Interview with LPN #2 on 09/13/19 at 10:00 AM revealed she provided care to Resident #1 on 09/04/19, but was unaware that the resident had an injury to his/her hand and had not assessed the resident's hand. LPN #2 stated she was not aware of the resident's injury until the resident's daughter asked her what happened to Resident #1's hand on 09/04/19. LPN #2 stated Resident #1's left hand was swollen in appearance and bruising, faded blue in color, was observed to his/her pinky finger (fifth digit). The LPN stated she had been trained to conduct a head-to-toe assessment of residents when bruising, especially with [MEDICAL CONDITION], was identified. In addition, she stated an incident report should have been completed, and ongoing monitoring should have been implemented to assess the resident every shift for the following seventy-two (72) hours. Continued interview with LPN #2 revealed she notified Resident #1's physician of the injury to Resident #1's hand on 09/04/19, and an order for [REDACTED].>Review of Resident #1's nurse's notes dated 09/04/19 at 11:59 PM revealed staff implemented an intervention to monitor the resident due to bruising and [MEDICAL CONDITION] to the resident's left outer hand. Review of a skin assessment dated [DATE] completed by Unit Manager (UM) #1 revealed Resident #1 had light purplish coloring with mild [MEDICAL CONDITION] to left pinky and outer hand. However, review of photographs taken by Resident #1's POA on 09/04/19 revealed [MEDICAL CONDITION] and light purple/brown bruising were observed to the lateral aspect of his/her left wrist, extending to the middle of the resident's fifth digit. The photographs also revealed bruising, blue in color, was observed inside the resident's palm and the front aspect of the resident's fifth finger. Light brown/purple bruising was also observed to the resident's left hand/knuckle area. Review of Resident #1's physician orders dated 09/04/19 at 2:58 PM revealed Physician #1 directed staff to do a stat x-ray of the resident's left hand due to bruising and [MEDICAL CONDITION]. Review of Resident #1's mobile x-ray report dated 09/04/19 of his/her left hand revealed Resident #1 was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed LPN #1 should have completed an assessment of Resident #1 when the bruising was observed to his/her left hand on 09/02/19, should have informed the oncoming shift of the injury, and should have implemented ongoing monitoring for seventy-two (72) hours to ensure the resident's condition was assessed. A post-survey interview with Physician #1 conducted on 09/16/19 at 2:00 PM revealed the physician expected staff to follow their policy and procedures when changes in a resident's condition occurred, which included bruising.

Based on interview, record review, review of a facility investigation, and review of facility policies, it was determined the facility failed to ensure residents who were diagnosed with [REDACTED].#1). Interviews with staff revealed Resident #1 had exhibited behaviors (flailing his/her arms and hitting/grabbing staff and/or bed rails) when care was provided. However, the facility failed to identify the behavior; subsequently, a person-centered care plan to address the resident's behavior was not developed. Bruising and [MEDICAL CONDITION] were observed to Resident #1's left hand on 09/02/19 and the resident was later diagnosed with [REDACTED]. The facility investigated Resident #1's injury and staff reported the resident's behavior, including LPN #1 who reported that he was sure the injury to the resident's hand was a result of the resident's behavior. However, the facility continued to fail to address the resident's behavior/dementia. The findings include: Interview with the Administrator on 09/13/19 at 4:30 PM revealed the facility had no policies related to care and treatment of [REDACTED]. Review of the facility policy titled Behavioral Tracking, not dated, revealed staff were required to document in the resident's clinical record facts that included the time an actual behavior occurred and consequences or outcome of the resident's behavior. Staff were also required to document target behaviors on the 24-hour report sheet, and notify the resident's physician of any changes in the resident's behavior. Review of Resident #1's medical record revealed the facility admitted the resident on 08/03/19 with [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident exhibited no behaviors (not hitting or grabbing). However, interview with SRNA #1 on 09/12/19 at 10:00 PM, SRNA #2 on 09/12/19 at 10:15 PM, and SRNA #3 on 09/12/19 at 10:30 PM revealed Resident #1 exhibited combative behavior when care was provided. SRNA #1 stated Resident #1 grabbed/hit the bed rails and flailed his/her arms when incontinence care was provided. SRNA #2 stated the resident grabbed his/her bed rails with a death grip, and grabbed staff while incontinence care was provided. SRNA #3 stated Resident #1 yelled out, would shake/grab his/her bed rails, and hit them (bedrails) sometimes because the resident would flail his/her arms when care was provided. The SNRAs stated they reported the resident's behaviors to staff; however, were not aware if the resident's behavior was addressed. Interview with LPN #1 on 09/13/19 at 10:30 AM revealed staff acknowledged that staff had reported Resident #1's combative behaviors. According to the LPN, he had also observed Resident #1 be up against his/her bed rails and grab staff and/or the bed rails when care was provided. However, LPN #1 stated, We don't document behaviors. Interview with LPN #2 on 09/13/19 at 10:00 AM revealed she was aware that Resident #1 was combative and flailed his/her arms, hitting the side rails when care was provided at times. LPN #2 stated she thought Resident #1 was confused and afraid when staff provided care. The LPN stated Resident #1's behaviors should have been reported to the MDS Nurse, the facility Social Worker, and/or the DON so the resident could be assessed and interventions implemented to prevent injury. LPN #2 stated she did not document the resident's behaviors because there was no process in place to monitor/document resident behavior. Review of a facility investigation revealed Resident #1 was observed with a bruise to his/her left fifth finger on 09/02/19. The investigation also revealed Resident #1 was diagnosed with [REDACTED]. Further review of the investigation revealed numerous staff members reported that they believed the cause of the resident's injury was a result of being combative. Staff statements revealed the resident slings his/her arms around and became anxious at times moving his/her arms through the air striking at things. LPN #1's statement when the bruise was identified revealed that he was sure the resident bumped it on the table or side rails of the bed. Interview with the facility Social Worker (SW) on 09/13/19 at 2:15 PM revealed she was aware that Resident #1 had a history of [REDACTED].#1 was combative with care. She stated that had she been aware, she would have discussed the resident's behavior with the clinical team, and interventions such as padding side rails or something to ensure Resident #1's safety would have been implemented. The SW stated she would have also retrained staff related to taking a step back, when facility residents became combative. Interview with the Director of Nursing (DON) on 09/13/19 at 3:40 PM revealed she was not aware that Resident #1 exhibited behaviors when staff provided care. However, the DON stated she was aware that Resident #1 would sling his/her arms around and some felt it was combative and some felt it was dementia. However, she acknowledged the facility was not monitoring/assessing the resident's behavior/dementia and had not implemented any interventions related to the resident's behavior/dementia. Interview with the Administrator on 09/13/19 at 4:30 PM revealed staff had been trained to document resident behavior on the facility's twenty-four (24) hour report forms, which were reviewed/discussed during a clinical meeting conducted Monday-Friday. Even though the facility investigation concluded on 09/09/19 revealed the facility identified Resident #1's behaviors, the Administrator stated she was not aware that the resident was combative with care. She also stated staff should have reported and/or documented Resident #1's combative behaviors so we would have known so the care plan could have been updated. A post-survey interview with Physician #1 was conducted on 09/16/19 at 2:00 PM. The physician stated he expected staff to follow the facility's policies and procedures related to dementia and resident behaviors.