Every finding on record at Landmark of Laurel Creek Rehabilitation and Nursin

Based on observation, interview, record review, facility policy review, and manufacturer guideline review, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 6 medication errors out of 25 opportunities affecting 6 (Residents 8, 66, 19, 38, 51, and 22) of 8 residents reviewed during the medication administration task, resulting in a medication error rate of 24%.Findings included: A facility policy titled, Insulin Administration, revised 01/05/2025, revealed, Prime the insulin pen by removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. Select the dose of insulin that has been prescribed by turning the dosage knob. Check that the dose is correct. Set the pen down without letting the needle touch anything. 1. A manufacturer Instructions for Use for a Admelog Solo Star pen, revised November 2019, indicated, Step 3: Do a safety test Always do a safety test before each injection to: - check your pen and the needle to make sure they are working properly. - Make sure that you get the correct insulin dose. 3A Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. 3B Press the injection button all the way in. - When insulin comes out of the needle tip, your pen is working correctly. An admission Record indicated the facility admitted Resident (R)8 on 11/10/2025. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus (disease where the body cannot use insulin properly resulting in high blood sugar levels that can damage other body organs) with hyperglycemia (high blood sugar level). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/2026, revealed R 8 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. R 8's Order Summary Report, for active orders as of 05/20/2026, revealed an order dated 11/10/2025 for Admelog Flex Pen subcutaneous solution pen injector 100 units/milliliter (mL), with instructions to inject 4 units subcutaneously with meals for diabetes. During a medication administration observation on 05/20/2026 at 1:17 PM, Registered Nurse (RN) 1 prepped and administered R 8's insulin. RN 1 did not prime the Admelog Flex Pen before she administered 4 units of Admelog subcutaneously to Resident 8. During an interview on 05/20/2026 at 5:12 PM, RN 1 stated she administered insulin to R 8, and she knew to prime the insulin pen with two units of insulin prior to dialing the prescribed dose of insulin for administration. She stated she did not prime the insulin pen prior to administering the insulin to R 8. 2. A manufacturer Instructions for Use Humulin N KwikPen, revised 06/2022, revealed the section titled, Priming your Pen, included, Prime before each injection. - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. Step 8: - To prime your Pen, turn the Dose Knob to select 2 units. Step 9: -Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 10: - Continue holding your Pen with Needle pointing up. Pushing the Dose Knob un until it stops and '0' is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. - You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 8 to 10, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 8 to 10. An admission Record indicated the facility admitted Resident 66 on 03/04/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus without complications. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2026, revealed R 66 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections five days during the assessment's seven-day lookback period. R 66's Oder Summary Report, for active orders as of 05/20/2026, revealed an order dated 04/24/2026 for Humulin N KwikPen Subcutaneous Suspension Pen Injector 100 units/milliliter, with instructions to inject as per sliding scale subcutaneously before meals for type 2 diabetes mellitus. During a medication administration observation on 05/20/2026 at 12:07 PM, Registered Nurse (RN) 1 prepped and administered R 66's insulin. RN 1 did not prime the Humulin N Flex Pen before she administered 6 units of Humulin N to R 66's abdomen. During an interview on 05/20/2026 at 5:12 PM, RN 1 stated she administered insulin to R 66, and she knew to prime the insulin pen with two units of insulin prior to dialing the prescribed dose of insulin for administration. She stated she did not prime the insulin pen prior to administering the insulin to R 66. 3. A manufacturer's information sheet titled, How to use your Novolog Flex Pen, with a copyright date of 2009, indicated, Step 2: Do an air shot (Prime the needle) 1. Dial 2 units. 2. Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle. 3. Press the push button on your syringe as far as it will go until a drop of insulin appears. An admission Record indicated the facility admitted Resident 19 on 02/01/2026. According to the admission Record, the resident had a medical history that included a diagnosis of type 1 diabetes mellitus (a chronic autoimmune disease in which the body's immune system attacks and destroys the insulin-producing cells in the pancreas, leading to little or no insulin production) with diabetic polyneuropathy (damage to multiple nerves from chronically high sugar levels). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2026, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident 19's Order Summary Report, for active orders as of 05/20/2026, revealed an order dated 01/26/2025 for Novolog PenFill Subcutaneous Solution Cartridge 100 units/milliliter, with instructions to inject as per sliding scale subcutaneously three times a day for DM (diabetes mellitus). During a medication administration observation on 05/20/2026 at 11:59 AM, Registered Nurse (RN) 1 prepped and administered R 19's insulin. RN 1 did not prime the Novolog Pen before she administered 2 units of Novolog to Resident 18's abdomen. During an interview on 05/20/2026 at 5:12 PM, RN 1 stated she administered insulin to R 19, and she knew to prime the insulin pen with two units of insulin prior to dialing the prescribed dose of insulin for administration. She stated she did not prime the insulin pen prior to administering the insulin to R19. 4. A manufacturer's information sheet titled, How to use your Novolog Flex Pen, with a copyright date of 2009, indicated, Step 2: Do an air shot (Prime the needle) 1. Dial 2 units. 2. Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle. 3. Press the push button on your syringe as far as it will go until a drop of insulin appears. An admission Record indicated the facility admitted Resident 38 on 09/08/2025. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus without complications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026, revealed R 38 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident 38's Order Summary Report, for active orders as of 05/20/2026, revealed an order dated 01/26/2025 for Novolog FlexPen Subcutaneous Solution Cartridge 100 units/milliliter, with instructions to inject as per sliding scale before meals and at bedtime related to type 2 diabetes mellitus without complications. During a medication administration observation on 05/20/2026 at 11:54 AM, Registered Nurse (RN) 1 prepped and administered R38's insulin. RN 1 did not prime the Novolog Pen before she administered 8 units of Novolog to Resident 38's abdomen. During an interview on 05/20/2026 at 5:12 PM, RN 1 stated she administered insulin to R 38, and she knew to prime the insulin pen with two units of insulin prior to dialing the prescribed dose of insulin for administration. She stated she did not prime the insulin pen prior to administering the insulin to R 38. 5. A manufacturer's information sheet title, How to use your Novolog Flex Pen, with a copyright date of 2009, indicated, Step 2: Do an air shot (Prime the needle) 1. Dial 2 units. 2. Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle. 3. Press the push button on your syringe as far as it will go until a drop of insulin appears. An admission Record indicated the facility admitted R 51 on 05/09/2026. According to the admission record, the resident had a history that included chronic kidney disease stage 3b (moderate to severe kidney function loss) and hypothyroidism (a medical condition where the thyroid gland does not produce enough thyroid hormone causing slow metabolism). Resident 51's Order Summary Report, for active orders as of 05/20/2026, revealed an order dated 05/19/2025, for Novolog FlexPen Subcutaneous Solution Pen Injector 100 units/milliliter, with instructions to inject as per sliding scale subcutaneously three times a day for DM (diabetes mellitus). During a medication administration observation on 05/20/2026 at 11:31 AM, Registered Nurse (RN) 2 prepped and administered insulin to R 51. RN 2 did not prime the Novolog Pen before she administered 8 units of Novolog to R 51's abdomen. During an interview on 05/20/2026 at 5:02 PM, RN 2 stated that she had been trained to prime the insulin pen with 2 units of insulin prior to dialing the pen to the prescribed dosage. RN 2 stated she did not prime the insulin pen prior to administration of insulin to R 51. 6. A manufacturer, [Name of manufacturer] Disposable Insulin Delivery Device User Manual, for insulin lispro revised 05/02/2025, revealed the section titled, III. Priming the Pen, included, - The Pen must be primed before each injection to make sure the Pen is ready to dose. Performing the priming step is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. - If you do not prime, you may get too much or too little insulin. An admission Record indicated the facility admitted R 22 on 07/03/2025. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus without complications. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2026, revealed R 22 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate impaired cognition. The MDS indicated that the resident received insulin injections daily during the assessment's seven-day lookback period. Resident 22's Order Summary Report, for active orders as of 05/20/2026, revealed an order dated 05/19/2026 for Insulin Lispro Subcutaneous Pen Injector 200 units/ml, with instructions to inject as per sliding scale subcutaneously before meals and at bedtime for diabetes. During a medication administration observation on 05/20/2026 at 11:24 AM, Registered Nurse (RN) 2 prepped and administered insulin to R 22. RN 2 did not prime the Humalog Pen prior to administering the insulin to R22. During an interview on 05/20/2026 at 5:02 PM, RN 2 stated that she had been trained to prime the insulin pen with 2 units of insulin prior to dialing the pen to the prescribed dosage. RN 2 stated she did not prime the insulin pen prior to administration of insulin to R 22. During an interview on 05/21/2026 at 10:00 AM, the Medical Director (MD) stated it was important to prime all insulin pens prior to dialing the prescribed dose to get the air bubbles out and deliver the correct amount of insulin to the resident. During an interview on 05/21/2026 at 3:20 PM, the Director of Nursing (DON) stated she expected insulin pens to be primed prior to dialing the insulin into the pen to get the air out of the pen and prevent medication errors. She stated that if an insulin pen was not primed, the resident would not get the correct dose of insulin. During an interview on 05/21/2026 at 2:52 PM, the Administrator stated he would defer his expectations of priming insulin pens to the DON.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a care plan to address a resident's noncompliance with the use of e-cigarettes for 1 (Resident 48) of 23 residents reviewed for care plansFindings included:A facility policy titled, Care Planning-Comprehensive Person-Centered, dated 01/01/2025, indicated, 15. Behavior Intervention Plan (BIP) may be developed when a resident exhibits behaviors that place the resident, other residents, or staff at risk or impedes on their rights. The policy further indicated, b. The BIP will be incorporated into the resident's comprehensive care plan. i. The BIP will be reviewed and updated as needed to address change in the resident behaviors. c. The BIP will clearly identify the behaviors being addressed, interventions/approaches to reduce behaviors, and expected outcomes. The BIP will also include consequences and action that may be taken should the resident not comply with the agreed expectations. and 16. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans.A facility policy titled, Smoking-Prohibited for Residents But Allowed for Staff, dated 10/01/2021, indicated, Smoking or vaping by residents, visitors, contractors, is prohibited within the facility, in any company owned vehicle or on facility grounds. The policy included, Definitions: 'Smoking': Includes the use of cigarettes, cigars, smoking or carrying a lighted or smoldering cigar, cigarette, or pipe of any kind. 'Vaping': refers to the use of electronic nicotine delivery systems or electronic smoking devices such as e [electronic]-cigarettes, e-pipes, e-hookahs, and e-cigars. The policy also indicated, 1. Prior to admission, all residents are notified of the facility's no smoking policy and sign acknowledgement of the no smoking policy upon admission and advised of the consequences involved in violation of the policy.An admission Record revealed the facility admitted Resident (R) 48 on 09/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, mood disturbance, anxiety, and lack of coordination. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2026, revealed R 48 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for mobility. Resident 48's Care Plan Report, included a focus area initiated 09/12/2025 for behaviors related to dementia and psychosis. The Care Plan Report revealed no focus area or interventions related to the resident vaping or the resident's non-compliance with the facility's tobacco-free policy and used vaping materials. During a concurrent observation and interview on 05/18/2026 at 10:42 AM, there were two pink electronic cigarettes (e-cigarettes) lying on R48's bedside table. Resident 48 stated their family member had brought the e-cigarettes to the facility and given them to the resident. During an interview on 05/18/2026 at 11:24 AM, Certified Nursing Assistant (CNA) 13 stated she had seen R48 with e-cigarettes that were brought in by the resident's family. She stated when she had seen an e-cigarette, she had removed it from the resident's room and took it to the nurse. During an observation and interview on 05/18/2026 at 12:40 PM, CNA 14 delivered R48's lunch tray and stated there was an e-cigarette on R48's bedside table. She stated she had not been told what to do when she saw an e-cigarette. During an observation and interview on 05/18/2026 at 1:09 PM, Licensed Practical Nurse (LPN) 17 entered R48's room and told them they needed to take the two e-cigarettes. She stated the resident's family brought the e-cigarettes to the resident. She stated she had confiscated an e-cigarette from the resident one time prior. During a telephone interview on 05/18/2026 at 1:20 PM, Responsible Party (RP) 18 stated a family member brought the e-cigarettes into the facility for the resident. During an interview on 05/19/2026 at 9:15 AM, CNA 15 stated she saw R48 had a pink e-cigarette the week prior and that she did not report it to anyone. During a telephone interview on 05/19/2026 at 7:20 PM, CNA 16 stated she saw R48 with an e-cigarette on 05/15/2026 between 11:00 PM and 12:00 AM. She stated she returned to the room to remove it but was unable to locate it. During a telephone interview on 05/20/2026 at 10:41 AM, R48's family member, (FM) 19 stated they had brought R48 an e-cigarette two to three weeks prior. During a telephone interview on 05/20/2026 at 11:11 AM, R48's family member, FM 20 stated they had brought R48 an e-cigarette the first week of May. During an interview on 05/19/2026 at 9:29 AM, the Social Services Director (SSD) stated R48 had used an e-cigarette in the past, but she did not remember exactly when. During an interview on 05/21/2026 at 12:47 PM, the SSD stated she was responsible for behavior care plans. She said she did not know if R48 needed a care plan for having an e-cigarette. During an interview on 05/19/2026 at 10:26 AM, the Director of Nursing (DON) stated R48 did not have a care plan for noncompliance with e-cigarettes. She stated she was aware the resident had been found with an e-cigarette a year prior, a month prior, and the previous day in their room. During a follow-up interview on 05/21/2026 at 1:01 PM, the DON stated the SSD was responsible for behavior care plans, and that noncompliance with e-cigarettes belonged in a behavior care plan. She stated a care plan should have been initiated the first time staff found an e-cigarette, and it should have included interventions for confiscating the contraband, assessing the resident for respiratory concerns, notifying the physician, requesting to check the resident's room, educating the resident and family on the risks, and reminding the resident and family of the facility policy. During an interview on 05/19/2026 at 10:44 AM, the Administrator stated he was aware R48 had possession of an e-cigarette in the facility a year prior. During a follow-up interview on 05/21/2026 at 2:09 PM, the Administrator stated there should have been a care plan in place for R48's noncompliance with e-cigarette use and that the care plan should have been initiated within 24 hours of the first e-cigarette being found.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible related to a resident maintaining vaping products in their room, which affected 1 (Resident 48) of 2 residents reviewed for smoking.Findings included: A facility policy titled, Smoking-Prohibited for Residents But Allowed for Staff, dated 10/01/2021, indicated, Smoking or vaping by residents, visitors, contractors, is prohibited within the facility, in any company owned vehicle or on facility grounds. The policy also indicated, 1. Prior to admission, all residents are notified of the facility's no smoking policy and sign acknowledgement of the no smoking policy upon admission and advised of the consequences involved in violation of the policy. An admission Record revealed the facility admitted Resident (R) 48 on 09/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD); unspecified dementia without behavioral disturbance, mood disturbance, and anxiety; and lack of coordination. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2026, revealed R48 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident was dependent for mobility. R48's Care Plan Report included a focus statement initiated 08/21/2025, that indicated that the resident was at risk for complications related to cognitive impairment secondary to dementia. The Care Plan Report revealed no specific focus area or interventions related to the resident vaping or for retention of vaping materials in the resident's room. An undated facility policy titled, Tobacco-Free Environment Policy, signed by R 48's Responsible Party (RP), RP 18, indicated, I understand and agree to enter a tobacco free Facility where I will not be allowed to use smoking or any other tobacco products as defined in the Tobacco-Free Facility Policy. The policy included Attachment D1, which revealed, Definitions: Tobacco and Tobacco Products, Any tobacco-containing or smoking product, including cigarettes, cigars, pipes, chewing tobacco, smokeless tobacco and e-cigarettes [electronic cigarettes]. During an observation on 05/18/2026 at 10:42 AM, there were two pink e-cigarettes on R48's bedside table. During an interview at the time of the observation, Resident 48 stated their family had brought the e-cigarettes into the facility and had given them to the resident. During an interview on 05/18/2026 at 11:24 AM, Certified Nursing Assistant (CNA) 13 stated she had seen R48 with e-cigarettes that were brought in by the resident's family. She stated that when she had seen an e-cigarette, she removed it from the resident's room and took it to a nurse. During an observation and interview on 05/18/2026 at 12:40 PM, CNA 14 delivered R 48's lunch tray and stated there was an e-cigarette on R 48's bedside table. She stated she had not been told what to do when she saw an e-cigarette. During an observation and interview on 05/18/2026 at 1:09 PM, Licensed Practical Nurse (LPN) 17 entered R48's room and told them they needed to take the two e-cigarettes. She stated the resident's family brought the e-cigarettes to the resident. She stated she had confiscated an e-cigarette from the resident one time prior. During a telephone interview on 05/18/2026 at 1:20 PM, RP 18 stated a family member had brought the e-cigarettes into the facility for the resident. During an interview on 05/19/2026 at 9:15 AM, CNA 15 stated she saw R 48 had a pink e-cigarette the week prior. She stated she did not remove it or report that the resident had the e-cigarette to nursing. She stated she did not know what the policy was regarding what to do if she saw an e-cigarette in a resident's room prior to 05/19/2026, but that the facility had provided a staff training that day regarding what to do. During a telephone interview on 05/19/2026 at 7:20 PM, CNA 16 stated she saw R 48 with an e-cigarette on 05/15/2026 between 11:00 PM and 12:00 AM. She stated she reentered the resident's room to remove it but was unable to find it. She stated she did not report to nursing that she did not remove it. During a telephone interview on 05/20/2026 at 10:41 AM, R 48's family member (FM), FM 19, stated they had brought R48 an e-cigarette two to three weeks prior. During a telephone interview on 05/20/2026 at 11:11 AM, R 48's family member, FM 20 stated they had brought R48 an e-cigarette the first week of May. During an interview on 05/18/2026 at 1:15 PM, the Director of Nursing (DON) stated that e-cigarettes put residents at risk for fire. She stated she expected staff to remove the e-cigarette when one was found and notify her. During a follow-up interview on 05/19/2026 at 10:26 AM, the DON stated she was aware R48 had an e-cigarette a year prior, a month prior, and the previous day. She stated that there had not been any measures put in place to ensure Resident 48 did not continue to have access to e-cigarettes. She stated that it was not required to document when the resident was found with an e-cigarette, and the facility had not been monitoring how often the resident was found to have one. She stated she did not know how many times the resident had an e-cigarette removed. During an interview on 05/19/2026 at 10:44 AM, the Administrator stated he was aware R 48 had an e-cigarette a year prior. He stated he expected to be notified every time an e-cigarette was found in a resident's room. He stated the facility did not have anything in place to monitor how often e-cigarettes were found.

Based on observation, interview, record review, facility policy review, and manufacturer's information, the facility failed to ensure a scheduled IV controlled substance was stored under proper temperature controls for a medication that required refrigeration for 1 (Cart 2) of 2 medication carts reviewed for medication storage.Findings included: A facility policy titled, Medication Storage, dated 01/05/2025, revealed, 9. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Further review revealed, 11. Scheduled II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. A Pharmaceutical Associates, Inc (incorporated) document titled, Lorazepam- lorazepam liquid, revised 05/2021, revealed Store at Cold Temperature. Refrigerate 2 [degrees] - 8 C [Celsius] (36 - 46 F [Fahrenheit]. A package insert titled, Lorazepam Oral Concentrate Package Insert/Prescribing Info [information], last updated 02/05/2026, indicated, Store at Cold Temperature-Refrigerate 2 -8 C (36 -46 F). A Patient Controlled Substance Administration Record - 'Liquids' form revealed the facility received a 30 milliliter (mL) bottle of lorazepam concentrate 2 milligrams (mg)/mL on 05/10/2026 for Resident (R)70. The form revealed that 30 doses of the medication had been administered, with the most recent dose administered to R 70 on 05/20/2026 at 12:30 PM. During a medication storage observation on 05/20/2026 beginning at 2:30 PM, medication Cart 2 located on the [NAME] wing of the facility revealed a large plastic disposable zipped bag labeled with R 70's name. The contents inside the bag included a paper medication box labeled Lorazepam Oral Concentrate USP [United States Pharmacopeia] 2 mg/mL that contained a bright pink sticker that indicated in bold letters REFRIGERATE. The box included instructions that the medication was to be stored at cold temperatures between 36 to 46 degrees Fahrenheit. During a concurrent interview, Registered Nurse (RN) 3 stated that the box containing R 70's lorazepam oral concentrate had been stored on the medication cart since the facility received it on 05/10/2026. RN 3 stated she had not been told the medication had to be stored in the refrigerator and had not noticed the label on the medication box that indicated the medication must be refrigerated. During an interview on 05/21/2026 at 10:03 AM, the Medical Director (MD) stated he was unsure what the stability of the lorazepam liquid concentrate would be if it was left at room temperature but expected all medications to be stored according to the manufacturer's storage recommended guidelines. During an interview on 05/21/2026 at 3:20 PM, the Director of Nursing (DON) stated she expected R 70's lorazepam oral concentrate to be stored behind double locks in the refrigerator, and the nurses should check the thermometer in the fridge to ensure the medication was stored at the correct temperature. The DON stated that if medications were not stored at the correct temperature, it could have adverse effects on the resident. During an interview on 05/21/2026 at 2:52 PM, the Administrator stated he expected the medication to be stored according to the manufacturer's guidelines or recommendations.

Based on observation, interview, record review, and facility document and policy review, the facility failed to have evidence of annual staff fit testing for respirator use and failed to ensure staff followed transmission-based precautions for 1 (Residents 29) of 5 residents reviewed for infection control. Findings included: 1. A facility document titled, Respiratory Protection Program Guide Long-Term Care Facilities, dated in 07/2023, revealed, under the heading, Fit Testing, included, Before an employee is required to use any respirator with a tight-fitting facepiece (anything except a Powered Air Purification Respirator, PAPR, with loose-fitting facepiece, hood, or helmet that does not rely upon a tight-fitting facepiece-to-face seal), she/he will be fit tested by the Infection Preventionist, or a designee thereof, with the same make, model, style, and size of respirator to be used. The guide further directed, Fit tests will be provided at the time of initial assignment and annually thereafter. Facility maps and calendars provided by the Infection Preventionist/Staff Development Coordinator (IP/SDC) as part of their COVID-19 infection surveillance tracking program, revealed evidence the facility had active resident and staff COVID-19 cases at the facility during the months of October 2025, January 2026, and March 2026. During an interview on 05/21/2026 at 9:03 AM, the IP/SDC stated that when she started her job, they told her she needed to do the fit testing, but she did not get certified in how to do the fit test. She stated she had been in her role since August 2025 and that employees hired after that time had not been fit tested. During an interview on 05/21/2026 at 10:46 AM, Registered Nurse (RN) 10 stated she was fit tested when she first started working at the facility in 03/2024 by the previous administration. During an interview on 05/21/2026 at 11:00 AM, Licensed Practical Nurse (LPN) 6, who was also a unit manager, stated that during the original COVID outbreak during the years from 2020 to 2022 everyone had been fit tested. She stated she was fit tested at that time. During an interview on 05/21/2026 at 1:31 PM, the Director of Nursing (DON) stated that the IP/SDC was newer in their role, and that the IP/SDC was in the process of getting certified to do the fit testing. The DON said no one had been fit tested since the IP/SDC took over that role. She stated her expectation was that fit testing be completed upon hire and annually. The DON stated they were unable to locate any evidence of fit testing for staff. During an interview on 05/21/2026 at 2:38 PM, the Administrator stated he had been employed at the facility for two years and had not received an annual fit test. He said he was last fit tested prior to his employment at the facility. The Administrator stated staff should be fit tested annually and upon hire. 2. A facility policy titled, Transmission-Based Precautions, last reviewed 10/24/2022, revealed, 'Contact Precautions': may be implemented for residents known or suspected to be infected with microorganisms transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Under a section titled, Contact Precautions the policy specified, 2. Personal Protective Equipment (PPE) included A. Gloves, which revealed, Staff and visitors will wear gloves when entering the room for all interactions that may involve contact with the resident and/or the resident's environment. The policy revealed, B. Gowns, which included a. Staff and visitors will wear a gown when entering the room for all interactions that may involve contact with the resident and/or the resident's environment. An admission Record revealed the facility admitted Resident 29 on 03/07/2025. According to the admission Record, the resident had a medical history that included diagnoses of traumatic brain injury, dementia, lack of coordination, and need for assistance with personal care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2026, revealed Resident (R) 29 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required supervision for eating and substantial to maximal assistance for chair/bed to chair transfer. R 29's Order Summary Report for active orders as of 05/18/2026, revealed an order dated 05/12/2026 for contact precautions every shift for seven days due to bacteria in their urine. A facility document titled, [Resident 29] (4010), dated 05/18/2026, revealed, the resident was on contact precautions due to bacteria in their urine, under the section titled, ADL [activities of daily living] Care. R 29's Care Plan Report, included a focus area initiated 05/13/2026, that indicated the resident had a urinary tract infection (UTI). Interventions directed staff that the resident was on contact precautions. During an observation on 05/18/2026 at 11:49 AM, a personal protective equipment caddy was observed with gowns and gloves hanging on the door for R 29. A contact precaution signage was also on the door. During an observation on 05/18/2026 at 12:15 PM, Certified Nursing Assistant (CNA) 21 entered R 29's room to deliver a lunch tray. CNA 21 did not don a gown or gloves prior to entering the room. CNA 23 followed CNA 21 into the room to deliver a lunch tray to R 29's roommate. CNA 23 did not don a gown or gloves prior to entering the room. CNA 22 entered the room and used a pulse oximeter to check R 29's oxygen saturation and their roommate's oxygen saturation. CNA 22 did not don a gown or gloves prior to entering the room. During an interview on 05/18/2026 at 12:19 PM, CNA 21 stated she delivered R 29's lunch meal tray. CNA 21 reviewed the signage on the resident's door and stated R 29 was on contact precautions. She stated she had been educated she was to wear a gown and gloves when entering the room but had not paid attention when she entered the residents' room. During an interview on 05/21/2026 at 9:38 AM, CNA 23 stated she had been trained to don a gown and gloves for residents on contact precautions and during direct patient care for residents on enhanced barrier precautions but was not trained to don a gown or gloves to deliver a meal tray. Therefore, she did not don a gown or gloves before entering the room. During an interview on 05/18/2026 at 12:24 PM, CNA 22 stated she entered R 29's room to check the oxygen saturation when she noticed neither of the residents were wearing their nasal cannula. She stated R 29 was on contact precautions, and their roommate was on enhanced barrier precautions. CNA 22 stated she had been trained to wear a gown and gloves to enter any resident room on contact precautions. She stated she normally worked on the other unit and did not notice the signage on the door before entering the room. CNA 22 stated she should have donned a gown and gloves before entering the room. During an observation on 05/18/2026 at 12:29 PM, CNA 13 entered R 29's room to assist the resident to transfer into their wheelchair. CNA 13 moved the overbed table from the resident's bed to the doorway, handed the resident a hat, then transferred the resident to the wheelchair and out the door of the room. CNA 13 was not observed to don a gown or gloves before entering the room. During an interview on 05/18/2026 at 12:31 PM, CNA 13 stated she was familiar with R 29 and had been trained to know if a resident was on transmission-based precautions by the colored dot next to the resident's name on the door outside the room. She stated she was unsure why R 29 was on contact precautions and did not pay attention to the signage on the resident's door before entering the room. She stated she had been trained to don a gown and gloves for residents on contact precautions. but did not apply either because she thought the signage was an enhanced barrier precaution signage for R 29's roommate. She stated that she should have donned a gown and gloves to help either resident. During an interview on 05/18/2026 at 1:00 PM, Registered Nurse (RN) 3 stated she was the assigned nurse for R 29. She stated she was unsure why R 29 was on contact precautions but observed the door and stated a contact precautions sign was displayed on the door. RN 3 stated that when any resident was placed on contact precautions, staff were to don a gown and gloves before entering the room to provide care. During an interview on 05/21/2026 at 9:03 AM, the Infection Preventionist/Staff Development Coordinator (IP/SDC) stated staff should don full PPE to deliver meal trays or check oxygen saturations to R 29 or the resident's roommate. She stated staff should wear a gown, gloves, goggles, and a mask for residents on contact precautions. During an interview on 05/21/2026 at 3:20 PM, the DON stated she expected staff to wear a gown and gloves when entering the room of a resident on contact precautions, and they were to treat both residents in the room as contact precautions if one was on contact precautions and the other was on enhanced barrier precautions. During an interview on 05/21/2026 at 2:52 PM, the Administrator stated he expected staff to wear PPE according to the signage for residents on contact precautions and stated all staff who entered the room of R 29 and should have worn a gown and gloves for all activities in the room.

Based on interview, record review, and review of the facility policy, the facility failed to develop and implement a baseline care plan which included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for one (1) of 23 sampled residents, Resident (R) 339. R339 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), encounter for orthopedic aftercare, and presence of right artificial hip joint. However, the facility failed to complete a baseline care plan to provide effective care within 48 hours of admission.The findings include: Review of the facility's Baseline Care Plans policy, undated, revealed a baseline plan of care to meet the resident's immediate needs should be developed for each resident within 48 hours of admission. Further review revealed a base line care plan included initial goals on admission orders and physician orders. Continued review revealed the resident and their representative would be provided a summary of the baseline line care plan which included the initial goals of the resident and a summary of the resident's medications. Review of R339's Face Sheet revealed the facility admitted the resident on 06/24/2025 with diagnoses encounter for other orthopedic aftercare, presence of right artificial hip joint, history of malignant neoplasm of ovary, and osteoarthritis. Review of R339's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/29/2025, revealed it was still in progress and had not been completed. Review of R339's Comprehensive Care Plan, dated 07/01/2025, revealed the resident was at risk for pain related to depression and a recent medical procedure. Further review revealed a goal that the resident would report satisfaction with her pain medication regime. Continued review revealed interventions to administer medications as ordered and a pain assessment as needed. Review of R339's Physician Orders revealed an order, dated 06/24/2025, for Oxycodone 10 milligrams (mg) every 4 hours as needed for severe pain. However, there was no evidence the facility care planned the resident's need for pain medication within 48 hours. During an interview, on 07/01/2025 at 1:20 PM, R339 stated she had received Oxycodone 10 mg as ordered from 06/24/2025 until 07/01/2025 when the nurse told her she only had a three-day order and would not give her the medication. She further stated she had been on the Oxycodone prior to the hip replacement, and it had been ordered by her oncologist when she was fighting cancer. She continued to state she was only in the facility for short-term rehabilitation following a hip replacement and she was unable to go to therapy on 07/01/2025 because of the pain.

The facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of 23 sampled Residents (R) (23, 20, 85).The findings include: Review of the facility’s policy, “Oxygen Administration,” undated, revealed steps in providing safe oxygen administration included to turn on the oxygen at the number of liters per minute as ordered by the physician/practitioner, be sure there was water in the humidifying jar with water level high enough the water bubbles as oxygen flows through, and periodically re-check the water level in the humidifying jar. Review of R85’s Medication Administration Record (MAR) revealed a physician's order for oxygen administration at two liters per minute. Review of R20’s Medication Administration Record (MAR) revealed a physician's order for oxygen administration at two liters per minute. Observation, on 06/29/2025 at 11:10 AM, revealed R85's oxygen concentrator set on three liters per nasal cannula with an empty water container, and nebulizer tubing attached to a nebulizer at the resident’s bedside which was not bagged while not in use. Observation, on 06/29/2025 at 11:30 AM, revealed R20’s oxygen concentrator set on four liters per nasal cannula with no water container, and nebulizer tubing attached to a nebulizer at the resident’s bedside which was not bagged while not in use. During an interview, on 06/29/2025 at 11:10 AM, R85 stated the facility adjusted her oxygen levels and she was unaware her water container was empty. During an interview, on 06/29/2025 at 11:30 AM, R20 stated the facility adjusted her oxygen levels. She further stated she didn’t know “anything” about the water container. During an interview, on 06/30/2025 at 4:05 PM, Licensed Practical Nurse (LPN) 3 stated R20 and R85 were ordered for oxygen at two liters per minute. During an interview, on 06/30/2025 at 4:10 PM, Registered Nurse (RN) 1 stated nurses check the oxygen settings and tubing at least every shift. He further stated if the oxygen is set at a higher rate than ordered, it could cause residents to become hypoxic and have a risk for the resident to stop breathing. He continued to state the water container was changed and filled weekly by the central supply staff. RN1 stated if the oxygen did not have humidity, it could cause irritation to the resident’s nasal passages. During an interview, on 07/02/2025 at 2:00 PM, the Infection Preventionist stated all oxygen and nebulizer tubing should be bagged when not in use to prevent the spread of germs because if it was not bagged it would be touching surfaces that had been touched by multiple people. During an interview, on 07/02/2025 at 3:00 PM, the Director of Nursing stated it was her expectation staff followed physician orders and administered oxygen per stated orders. Observation on 06/29/2025 at 10:50 AM and at 12:00 PM revealed Resident 23 (R23) who was ordered to receive Oxygen (O2) therapy via a nasal cannula and was observed to have the nasal cannula on. However, the tubing was disconnected from the concentrator and lying in the floor. When staff was made aware, LPN 2 picked up the tubing from the floor and connected it to the concentrator without cleaning, sanitizing or changing the tubing.Review of the facility policy titled Oxygen Administration undated, revealed the purpose was to provide guidelines for safe oxygen administration.Review of Resident 23's face sheet revealed he was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and Diabetes.During an interview on 06/29/2025 at 12:05 PM with LPN2, she stated she should have obtained a new tubing for R23 due to potential contamination from lying in the floor. LPN2 further stated the Resident could be at risk for respiratory issues due to the oxygen and or contaminates going directly into the respiratory system. During an interview on 06/30/2025 at 4:10 PM with Registered Nurse (RN)1 he stated the oxygen saturation, the oxygen setting, and the tubing should be checked every shift by the nurse.During an interview on 07/02/2025 at 3:00 PM with the Director of Nursing (DON) she stated her expectation was for staff to follow the Oxygen policy.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure pain management was provided as ordered for one of 23 sampled, Resident (R) 339.The findings include:Review of the facility's policy, Pain Management, undated, revealed the organization would ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.Review of the facility's policy, Medication and Treatment Orders, undated, revealed medications would be administered upon the written order of a person duly licensed and authorized to prescribe such medications. Further review revealed drug orders must be recorded on the physician's order sheet in the resident's medical record.Review of R339's Face Sheet revealed the facility admitted the resident on 06/24/2025 with diagnoses encounter for other orthopedic aftercare, presence of right artificial hip joint, history of malignant neoplasm of ovary, and osteoarthritis.Review of R339's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/29/2025, revealed it was still in progress and had not been completed.Review of R339's Comprehensive Care Plan, dated 07/01/2025, revealed the resident was at risk for pain related to depression and a recent medical procedure. Further review revealed a goal that the resident would report satisfaction with her pain medication regime. Continued review revealed interventions to administer medications as ordered and a pain assessment as needed.Review of R339's physicians orders revealed an order for Oxycodone 10 milligrams (mg) every four hours as needed for severe pain.Review of R339's June 2025 Medication Administration Record (MAR) revealed the resident had an Oxycodone documented as given on 06/30/2025 at 1:18 PM and no further pain medication was documented on the June 2025 or July 2025 MAR prior to 07/01/2025 at 1:20 PM.Review of R339's Controlled Drug Receipt/Record/Disposition Form for Oxycodone 10 mg revealed the medication was signed out on 06/30/2025 at 6:30 PM and 10:30 PM, and on 07/01/2025 at 3:30 AM and 2:00 PM.Observations on 06/29/2025 and 06/30/2025 revealed R339 up in room in cheerful mood with no complaints voiced. Observation, on 07/01/2025 at 1:20 PM, revealed resident was sitting on side of bed tearful.During an interview, on 07/01/2025 at 1:20 PM, R339 stated she had been told she could not have her pain medication because it was only a three-day order and she was trying to get in touch with her doctor to get a refill. She further stated she could not attend therapy on 07/01/2025 because she was in too much pain.During an interview, on 07/01/2025 at 1:30 PM, with the Unit Manager who was R339's primary nurse, she stated the resident only had an order for Oxycodone for three days, which had ended, and she messaged the doctor regarding the order. She further stated R339 was drug seeking.During an interview, on 07/01/2025 at 4:15 PM, R339 stated the nurse had given her a pain pill this afternoon and pain had improved. She further stated she was able to attend physical therapy after receiving the pain medication.During an interview, on 07/01/2025 at 4:20 PM, the Unit Manager stated she had called the physician and received permission to give the resident one pain pill until the physician came to the building to see her tonight.During an interview, on 07/02/2025 at 11:45 AM, the Unit Manager stated R339's Oxycodone order had no stop date, and she wanted to clarify with the physician if R339 could continue the medication. During an interview, on 07/02/2025 at 3:00 PM, the Director of Nursing stated nurses should follow physician orders and assess the resident's pain as needed.

§483.45(g) Labeling of Drugs and Biological's and §483.45(h) The facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one of five sampled residents. Resident (R)#1. On [DATE] the Licensed Practical Nurse (LPN) 2 administered Med-Pass to R1 that had expired per manufacturers recommendations. The findings include: Observation on [DATE] at 12:10 PM revealed Licensed Practical Nurse (LPN) # 2 poured Med-Pass 2.0 (a nutritional shake) from a multi-dose carton, which had an open date of [DATE]. Resident # one, (R1) was handed the Med-Pass in a cup to drink. Review of the facility policy titled, Medication Storage, not dated, revealed no instructions pertaining to labeling of nutritional supplements. However, review of the Med-Pass 2.0 manufacturer's direction on the carton revealed after opening, the product should be consumed in four days if properly refrigerated, or within 4 hours if not refrigerated. Review of R1's Face Sheet revealed resident was admitted to the facility on [DATE] with diagnoses of Intellectual Disabilities, Atrial Fibrillation, and Postural Kyphosis. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the Brief Interview for Mental Status (BIMS) could not be administered due to the resident's poor cognitive status. Interview on [DATE] at 12:25 PM with LPN 2 revealed she wasn't sure of when the Med-Pass should be discarded, she thought it was 30 days after opening. LPN2 further stated she normally uses the entire container during the medication pass but had run out during this medication pass and obtained the opened/dated carton from the refrigerator. She further stated the Med-Pass should have been disposed of on [DATE]. LPN 2 stated she receives education monthly from the facility as well as online. She further stated giving expired Med-Pass to the resident could cause gastrointestinal issues. During an interview with the Director of Nursing on [DATE] at 3:00 PM she stated her expectation was for the staff to follow the policy as well as the manufacturers' recommendations regarding storage and disposal.

Based on observation, interviews and review of the facility policy, the facility failed to establish and 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 all residents, staff, volunteers, visitors and other individuals providing services. The sample census was 23.The findings include: Review of the facility’s “Infection Control Program”, signed 03/10/2025, revealed the facility had an infection control program and committee that addressed the surveillance, prevention, and control of disease and infection consistent with the guidelines from the Centers for Disease Control (CDC) and the federal Occupational Safety Hazard Agency (OSHA) blood borne pathogens regulations. Review of the facility’s “Hand Hygiene” policy, undated, revealed all staff were responsible for hand hygiene procedures after contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident and before and after wearing gloves. Observation, on 06/30/2025 during the lunch meal, revealed HK1 with her cleaning cart cleaning the residents’ hallway when meal trays arrived. The facility staff opened the tray cart and began passing lunch trays to residents. HK1 pushed her cart down the hallway to the closet and parked the cart in the hallway while she opened the closet door with a key. Facility staff were noted to push the tray cart next to the cleaning cart and open the cart door to get more trays off the cart and take to residents. HK1 then pushed the cleaning cart into the closet, disposed of her gloves in the trash bin on the cart, then closed the closet door and walked down the hallway (past the nurse’s station) to the doorway of a resident room to retrieve a wet floor sign, without hand hygiene. During an interview, on 06/30/2025 at 12:45 PM, HK1 stated she had worked in the facility for 5 months and was aware the cleaning cart needed to be put up when resident trays were out so they wouldn’t be running into each other, and she was supposed to have the cart off the floor before trays arrived. She continued to state it could be an infection control issue with the items she had on her cart encountering the residents’ meal trays. She further stated she should have performed hand hygiene when she took her gloves off to prevent the spread of germs. During an interview with the Infection Preventionist, on 07/02/2025 at 2:00 PM, she stated staff received training on proper hand hygiene and the facility monitored for proper hand hygiene through Ambassador rounds daily. She further stated cleaning carts should be off the floor at mealtime because they contained dirty items and garbage, as well as supplies that should not be out close to residents’ meal trays. She continued to state staff not performing proper hand hygiene could lead to the spread of infection. Observation on 07/01/2025 at 9:38 AM of Resident (R) 43 being transferred from his bed to the wheelchair revealed the use of a Hoyer lift. Upon completion of the R43 being transferred to his wheelchair, from the Hoyer Lift. The Hoyer lift was removed from the room and placed across the hall in a dayroom. No cleaning was noted of the Hoyer lift before or after the use of the lift.Review of the facility policy titled Cleaning and Disinfecting Resident Care Items and Equipment dated 10/01/2021, revealed, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. Furthermore, reusable items were to be cleaned and disinfected or sterilized between residents (e.g. stethoscopes, and durable medical equipment).Review of the facility policy titled Enhanced Barrier Precautions (EBP) Policy dated 03/28/2024 revealed the purpose of the policy was to outline the guidelines for implementing EBP to reduce the transmission of multi drug-resistant organisms (MDROs) within the facility. EBP was to be used in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. Further review of the policy revealed if a resident had a wound or indwelling medical device EBP were to be utilized during high-contact resident care activities such as transferring the resident.Review of Resident 43's Face Sheet revealed he was admitted to the facility on [DATE] with a diagnoses of Hemiplegia following Cerebral Infarction affecting right side, contractures of right upper and lower extremities.During an interview on 07/01/2025 at 10:07 AM with Certified Nursing Assistant (CNA) #9 she stated after using the Hoyer Lift, it is placed in the breakroom until used again. She further stated there is a storage area where they are also placed. CNA9 further stated the Hoyer Lifts are cleaned at the end of the day and the lift pads are cleaned after the resident is put back to bed. CNA 9 continued to state there was no need to clean the Hoyer lift between residents as the residents didn't come in contact with the other areas of the lift, but only the lift pad that was under the resident during transfer. During an interview on 07/02/2025 at 2 PM with the Infection Preventionist she stated her expectation was to follow the infection control policy regarding multi-use devices cleaning.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to revise the person-centered Comprehensive Care Plan (CCP) to include measurable objectives and timeframes to provide services that met standards as related to care plan revision by the Interdisciplinary Team (IDT) after each assessment for five (5) of nine (9) residents, Residents #1, #2, #3, #7, and #8. 1. Review of Resident #1's Comprehensive Care Plan (CCP), initiated [DATE], revealed the facility assessed the resident as at risk for falls with interventions noting the resident required staff support and assistance for toileting. However, the facility provided Resident #1 a bedside commode on [DATE], and interviews revealed the resident attempted to toilet himself/herself without the staff's assistance. Staff interviews revealed they felt Resident #1 required additional supervision. The facility failed to care plan Resident #1 for additional supervision and monitoring for accident prevention and failed to discuss the resident's risk versus (vs.) benefits if he/she sustained a fall while on his/her blood thinner medication. Therefore, on [DATE], Resident #1 experienced a fall while attempting to toilet himself/herself on the bedside commode which resulted in serious injury to the resident, subsequently, the resident died on [DATE]. 2. Review of Resident #2's Comprehensive Care Plan (CCP), initiated [DATE], revealed the facility assessed the resident as at risk for falls with a goal for the resident to be free from falls and fall-related injuries. The facility implemented interventions to keep Resident #2's bed in the lowest position and assist the resident with mobility and transfers. However, there was no documented evidence the facility discussed Resident #2's risk vs. benefit regarding accidents, should he/she experience a fall while on Plavix (medication to prevent blood clots) and care plan the resident for that risk. Additionally, the facility failed to care plan Resident #2's mental status changes which occurred as a result of a urinary tract infection (UTI) and required additional supervision and monitoring of the resident to prevent accidents. As a result of the facility's failures Resident #2 sustained a fall on [DATE], from his/her bed which was in the highest position. The fall resulted in Resident #2 sustaining a left temporal subarachnoid hemorrhage, fracture of the right temporal bone, and large right subdural hematoma. Resident #2 expired on [DATE], as a result of trauma sustained during the fall. 3. Review of Resident #3's Baseline Care Plan (BCP), dated [DATE] revealed the facility care planned the resident as at high risk for falls related to a history of falls and decreased safety awareness. The facility care planned Resident #3 for his/her activities of daily living (ADL's) which had been assessed as he/she required assist of one (1) person for his/her selfcare needs, and toileting, and two (2) person assist with mobility, and transfers related task. However, the facility failed to care plan Resident #3's risk vs. benefits, or potential for harm if the resident experienced a fall while taking his/her anticoagulant medication on admission and failed to revise the care plan for the need for additional supervision or level of assistance the resident required. Therefore, Resident #3 experienced a fall from his/her bed on [DATE], and fell again on [DATE], from his/her wheelchair hitting his/her head on the floor both times. The facility transferred Resident #3 to the hospital, where the resident was diagnosed with a severe subarachnoid hemorrhage. 4. The facility assessed Resident #7 as a high risk for falls and as taking an anticoagulant medication for his/her diagnosis of Atrial Fibrillation (A-fib). However, the facility failed to care plan Resident #7 for adverse effects of the anticoagulant if he/she experienced a fall while taking the medication which could result in serious injuries. The facility's interventions for Resident #7 included staff to assist the resident to the bathroom and check on him/her every two (2) to three (3) hours. On [DATE], at approximately 10:51 AM, Resident #7 experienced an unwitnessed fall with major injury while attempting to toilet on his/her own. Resident #7 complained of severe right hip pain, and was sent to the hospital emergency room (ER) and admitted to the hospital. Resident #7 was diagnosed with a displaced right femoral neck fracture and underwent a right hip hemiarthroplasty. Resident #7 returned to the facility on [DATE], where he/she sustained three (3) additional falls from that date to [DATE]. However, the facility failed to update Resident #7's care plan with additional interventions to address the resident's need for increased supervision or the level of assistance he/she required. 5. The facility care planned Resident #8 with interventions which included: checking on the resident every two (2) to three (3) hours and as needed, providing incontinence care as needed; ensuring the resident's bed was in the low position and his/her call light was in reach; informing the resident to ask for assistance with ambulation, and ensure he/she was wearing appropriate footwear. Resident #8 sustained four (4) falls from [DATE] to [DATE], with the one (1) on [DATE], resulting in injury to the resident. On [DATE], Resident #8 sustained a fall from his/her bed and complained of pain in his/her right elbow. The resident was sent to theER on ,d+[DATE] and was diagnosed with a closed fracture of the 4th and 5th metatarsal bones. However, the facility failed to revise Resident #8's care plan with additional interventions for his/her need for further supervision related to his/her noncompliance, Physician's request for the resident to have a protective weight bearing status and use of a walker, or for the Orthopedic consult scheduled for [DATE]. The facility's failure to ensure staff revised residents' Comprehensive Care Plans (CCPs) in a timely manner has caused or is likely to cause serious injury, harm, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices (F689); at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Care Plan Timing and Revision (F657); at 42 CFR 483.70 Administration (F835); and at 42 CFR 483.75 Quality Assurance and Performance Improvement, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt (F865) all at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE]. The findings include: Review of the facility's policy titled, Care Plan Process, revised [DATE], revealed each resident's plan of care must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Continued review of the policy revealed residents' care plans were to incorporate identified problem areas and be reviewed and revised periodically by the Interdisciplinary Team (IDT), Director of Nursing (DON), or Registered Nurse (RN) designee. 1. Review of Resident #1's closed Electronic Medical Record (EMR) revealed, the facility admitted the resident on [DATE], with diagnoses to include Atrial Fibrillation (A-fib), Congestive Heart Failure (CHF), and a History of Myocardial Infarction. Continued review of the closed EMR revealed the facility assessed Resident #1 to be a falls risk. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE], and Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated intact cognition. Continued review of the MDS Assessments revealed the facility assessed Resident #1 to require extensive physical assistance of two (2) staff with his/her Activities of Daily living (ADL's) with bed mobility, transfers and walking in his/her room. Review of Resident #1's Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL's) self-care deficit, initiated on [DATE], and revised on [DATE], revealed the resident required assistance with ADL care including toileting, bathing, personal hygiene, bed mobility, and transfers. Per review, the goal was the resident would not develop any complications related to decreased ADL self-performance through the next review. Continued review revealed Resident #1's interventions included: assisting him/her to the bathroom as needed; providing incontinence care as indicated; assisting up in the wheelchair; turning, repositioning, and shifting the resident as indicated. Per review of the CCP, Resident #1 was also care planned as at risk for falls, related to deconditioning, gait and balance problems, and impaired range of motion (ROM). Review of the at risk for falls care plan revealed a goal for the resident to have a safe environment, and that included: partial bed rails up with cane rails as an enabler for mobility when in bed; gathering information on past falls and attempting to determine the root cause of a fall, ensuring his/her call light was within reach and encouraging its use, for assistance as needed. Review of the at risk for falls care plan further revealed staff were to respond promptly to all requests for assistance from the resident and anticipate and meet his/her individual needs. Continued review of Resident #1's CCP additionally revealed the facility care planned him/her on [DATE], for use of Coumadin (anticoagulant medication) due to the diagnosis of Atrial Fibrillation (A-fib). Review of the care plan revealed the interventions included; administering the anticoagulant medication as ordered; monitor for side effects and effectiveness every shift; perform a daily skin inspection and report abnormalities to the nurse; laboratory (labs) as ordered and report abnormal lab results to the Physician; and Vitamin K antidote for bleeding emergencies. Review of the Facility Investigation dated [DATE] at approximately 11:30 PM to 12:05 AM (AM marked out) for Resident #1 revealed staff had found the resident lying face down on the floor in his/her room. Per review, Resident #1 reported he/she had gotten up to use the bedside commode and fell . Continued review of the Investigation revealed Resident #1's call light had been in reach; however, had not been turned on. Further review revealed there had been no witnesses to the fall, and the BSC was listed as an environmental hazard which was present on the facility's Investigation documentation. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 4:09 PM, revealed Resident #1 used a BSC and required staff's assistance with his/her care, including using the BSC. CNA #1 stated Resident #1 would sometimes ring out to ask for assistance; however, he/she often tried to get up and do things on his/her own, such as using the BSC without calling for staffs' assistance. CNA #1 further stated staff reinforced and encouraged Resident #1 to use his/her call bell to request assistance and encouraged him/her not to get up on his/her own to prevent injury. Interview with Registered Nurse (RN) #1 on [DATE] at 1:34 PM. revealed Resident #1 required encouragement and reinforcement to use his/her call light to request assistance to use the BSC, so the staff knew to check on him/her routinely. Further interview revealed RN #1 reported staff had been trained to monitor Resident #1 for noncompliance with assistance and to ensure the BSC was in the correct position at the end of the bed. Interview with RN #3 on [DATE] at 10:50 AM, revealed she was familiar with Resident #1, and recalled the resident required assistance. She stated, however, most of the time Resident #1 got up and used the BSC on his/her own. Continued interview with RN #3 revealed she did not believe Resident #1 had been assessed as a falls risk, or that the resident had required any additional monitoring. Per RN #3, Resident #1 had only required encouragement to use his/her call light. Further interview revealed RN #3 had been aware Resident #1 was on Coumadin to prevent blood clots; however, she was not aware of any care planned interventions such as an antidote for the anticoagulant medication, or a risk vs benefit if the resident sustained a fall while on the blood thinner. Interview with RN/Unit Manager on [DATE] at 2:00 PM, revealed the facility did not increase Resident #1's supervision level to one on one (1:1) supervision due to it not being feasible with the number of staff to provide care. Further interview revealed however, it was imperative the facility addressed residents' falls and provided additional observation and supervision to protect residents from injury and ensure their safety. Interview with the Medical Director on [DATE] at 5:24 PM, revealed she had met with Resident #1 two (2) days prior to the fall incident on [DATE], and the resident had been doing well. The Medical Director stated she noted Resident #1 had some hip pain and ordered Tylenol for pain control. Per the Medical Director, she had been aware Resident #1 used a BSC to toilet and required additional support and supervision for transferring to the BSC to prevent potential injury from a fall. 2. Review of Resident #2's closed Electronic EMR revealed the facility admitted the resident on [DATE], with diagnoses which included a history of Urinary Tract Infections (UTIs). Review of Resident #2's Admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of ten (10), which indicated moderate cognitive impairment. Continued review revealed the facility also assessed Resident #2 to require extensive physical assistance of two (2) persons for bed mobility, transfers, and locomotion on/off unit, dressing, toilet use, and personal hygiene. Review of Resident #2's CAA assessment dated [DATE], revealed the facility assessed the resident as at risk for falls due to decreased mobility and deconditioning, difficulty maintaining sitting balance, and impaired balance during transitions. Continued review revealed the assessed medication factors included antidepressants, antianxiety agents, and opioids. Review revealed the facility assessed internal risk factors for Resident #2 included neuromuscular, functional, psychiatric or cognitive issues, anxiety disorder, and depression. Additional review revealed the facility's care plan considerations related to falls were to be addressed. Review of Resident #2's Comprehensive Care Plan initiated on [DATE], revealed the facility had care planned the resident as at risk for falls related to impaired balance and mobility, and use of psychotropic medications. Continued review revealed the facility's goal for Resident #2 was for him/her to be free from falls and fall related injuries. Per review of the care plan, the facility's interventions included keeping Resident #2's bed in the lowest position, anticipating the resident's needs, assisting with his/her mobility and transfers, maintaining a clutter free environment, placing the call bell within reach and observing for any side effects of medications. Further review revealed however, no documented evidence the facility had discussed with Resident #2 the risks vs. benefits of being on an anticoagulant medication and potential for injuy related to accidents if he/she should have a fall while on the Plavix (anticoagulant medication). In addition, review also revealed no documented evidence the facility care planned Resident #2's for UTIs and resulting mental status changes, which required additional supervision and monitoring to prevent accidents. Review of the facility's Event Summary Report for Resident #2 dated and signed by the DON on [DATE], revealed at approximately 7:30 PM, the resident was found lying on the floor next to his/her bed. Continued review revealed Resident #2 returned from the ER approximately thirty (30) minutes prior to the fall and observed to have a change in mental status and behavioral symptoms. Further review revealed Resident #2 had been diagnosed with a UTI while at the ER and Intravenous (IV) antibiotics were given. Review of the facility's Investigation documentation dated [DATE], revealed no root cause analysis had been performed. Per review, the results/conclusion revealed Resident #2 had fallen out of bed after returning from the ER, and sustained another fall resulting in a head injury. Further review revealed Resident #2 was sent back to the ER. In addition, review revealed no documented evidence the facility had taken corrective action, and the Administrator's signature, dated [DATE]. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 11:50 AM, revealed Resident #2 required total assistance. Further interview revealed CNA #1 was not fully aware of Resident #2's care plan interventions specific to falls; however, she felt all residents were at risk for falls and the care plans should be reviewed and residents monitored to protect them from injury related to a fall. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 11:50 AM, revealed Resident #2 had a history of confusion at times and would push his/her bed up and down; however, would not remember why he/she pushed it, especially, if the resident had an infection or a UTI. LPN #2 stated Resident #2 required total care and had been in the ER the morning of [DATE], and diagnosed with a UTI. Continued interview with LPN #2 revealed when Resident #2 returned to the facility he/she had been experiencing confusion, and when the LPN entered the room later on, she found Resident #2 lying on the floor with a lot of blood. She stated, EMS was called and LPN #2 and the CNAs remained with the resident until emergency management services (EMS) personnel arrived. Further interview revealed the care plan was important because it told staff what care a resident needed, and how to provide that care. In addition, LPN #2 stated it was important Resident #2's care plan to have been updated based on the resident's needs and with any status changes, to include confusion and UTI's. Interview with Registered Nurse (RN) #1 on [DATE] at 3:48 PM, revealed when a resident had a change of condition, she would not revise the resident's care plan to implement additional interventions. She stated she waited until she notified the DON or MDS Coordinator and then the care plan would be revised if needed. She stated it was important for residents' care plans to be revised with any immediate changes related to falls to prevent injuries. Continued interview revealed each resident was to have a specific individualized care plan that met their assessed needs. The RN stated all staff was to be up to date with residents' care plans and review their interventions and goals routinely in order, to provide the best appropriate care and prevent potential harm or injury to a resident. RN #1 further stated the facility failed to address the change in condition for Resident #2 by updating his/her care plan upon returning to the facility from theER on [DATE], prior to the second fall. Interview with LPN #1 on [DATE] at 10:12 AM, revealed Resident #2 returned to the facility between 7:00 PM and 7:10 PM and was anxious and agitated. Per interview, RN #1 asked LPN #1 to hang IV fluids for Resident #2 around 7:35 PM. LPN #1 stated upon entering Resident #2's room to hang the fluids, she found Resident #2 lying on the floor next to his/her bed attempting to get himself/herself up off the floor. LPN #2 revealed it was the nurses' responsibility to update residents' care plans. In addition, she stated she did not always have time to go over her residents' care plans every day. Interview further revealed however, it was important for Resident #2's care plan to have been updated based on his/her needs and condition change status including confusion and UTI's. Interview with the Unit Manager (UM) on [DATE] at 1:10 PM, revealed Resident #2 required total care and experienced delusional behaviors at times. Continued interview revealed on the day of the incident ([DATE]), Resident #2 had been experiencing increased behaviors and confusion, weakness, was requiring increased assistance, and had not been eating as well or participating in his/her care. Continued interview revealed Resident #2 was sent out to the ER for evaluation and returned to the facility later on with a diagnosis of UTI. The UM stated following Resident #2's return to the facility, he/she was found on the floor by staff. Per interview, Resident #2's bed had been in the highest position with the call light and bed control in his/her hand. The UM further stated there was no certain facility plan or procedure in place for monitoring and supervising residents; however, the nurses and CNAs were responsible for knowing their resident's needs and care, and it was the staff's responsibility to ensure the safety of residents. 3. Review of Resident #3's closed Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE], with diagnoses that included A-fib and Dementia. Continued review of the resident's closed EMR revealed Resident #3 had been admitted with confusion and being unaware of his/her surroundings. Review of Resident #3's Baseline Care Plan dated [DATE], revealed the facility noted the resident was at risk for falls related to a history of falls and decreased safety awareness. Continued review revealed the facility also noted Resident #3 had impaired range of motion and/or loss of functional movement of joint(s), required one (1) person assistance with toileting and two (2) person assistance with mobility, and transfers. Per review of the Baseline Care Plan, interventions for Resident #3 included floor mats at bedside; gather information on the resident's past falls and attempt to determine the root cause of falls; anticipate and intervene to prevent reoccurrence of falls; be sure his/her call light was within reach and encourage the resident to use it for assistance as needed. Review further revealed other interventions included: staff to respond promptly to all the resident's requests for assistance; and anticipate and meet the individual needs of the resident. Further review revealed however, no documented evidence the staff discussed and care planned the risk vs. benefits with Resident #3 the potential for harm if the resident fell while being on anticoagulants. In addition, review revealed no documented evidence Residen#3's care plan was revised to include a need for increased supervision or level of assistance needed when the resident was up in a wheelchair after he/she sustained a fall on [DATE]. Interview with Resident #3's daughter on [DATE] at 11:48 AM, revealed she and other family members told staff on the resident's admission, that he/she had confusion and a history of falls. Continued interview revealed she informed nursing staff of the need and importance of keeping a close eye on Resident #3 and to check on him/her often to keep the resident safe. Interview with Certified Nursing Assistant (CNA) #3 on [DATE] at 12:00 PM, revealed Resident #3 had been a two (2) person assist with transfers and she was aware of the resident's interventions on his/her care plan. Interview revealed however, she was not aware of additional supervision for Resident #3 to include direct 1:1 supervision of the resident while up in his/her wheelchair, after the fall on [DATE]. CNA #3 stated on the day of the incident ([DATE]) she had not had prior contact with Resident #3 before he/she experienced the fall. Further interview revealed while passing meal trays that day she heard a noise and found Resident #3 lying on the floor. CNA #3 further stated she felt it had just been a few minutes that Resident #3 was left alone without supervision at the nurse's station. Interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 11:50 AM, revealed Resident #3 was to have been be up in a wheelchair in front of the nurse's station before meal trays due to his/her confusion and being a fall risk. She stated staff had been aware to keep an eye on Resident #3 due to being a new admission, and his/her history of confusion and falls. Continued interview with LPN #3 revealed on the day of the incident ([DATE]) Resident #3 had experienced increased confusion earlier that day and had been moved to the nurse's station for increased monitoring and supervision. LPN #3 stated Resident #3 had been fidgety and removing his/her clothes. Per interview, Resident #3 had been eating his/her dinner by the nurse's station while the nurse was passing medications. Interview revealed while passing medications, she heard something, and CNA #3 yelled that Resident #3 had fallen out of his/her wheelchair. LPN #3 further stated she was aware of residents' baseline care plans; however, she was unfamiliar with how to update the care plans following an incident. In addition, she stated the facility did not provide 1:1 supervision, and said, it's impossible to keep an eye on all residents twenty-four (24) hours a day seven (7) days a week. LPN #3 additionally stated staff could walk away for a second and anything could happen. Interview with Registered Nurse (RN) #4 on [DATE] at 12:15 PM, revealed Resident #3 had to be monitored closely and bolsters were to be present on both sides of his/her bed due to his/her recent fall on [DATE]. RN #4 stated Resident #3 had been moved to the nurse's station in a wheelchair earlier on the day of the incident involving the injury ([DATE]) to help the resident relax following his/her increased confusion that morning. Further interview revealed she was not certain what Resident #3's level of care or care needs had been but stated she would refer to a resident's care plan to know that information. The RN additionally stated when a resident's care plan was not followed or revised, staff could injure the resident or themselves, or could result in falls with injuries. Interview with the RN/Unit Manager (UM) on [DATE] at 2:00 PM, revealed the facility had no certain process or procedure in place for additional supervision of residents; however, staff were provided education and daily report on residents with noncompliance, falls, and mental status changes. In addition, she stated the staff were all responsible for knowing their residents and to keep an extra eye on them to ensure their safety. Further interview additionally revealed the facility had no set schedule or procedure which was enforced for monitoring to provide additional supervision of residents. 4. Review of Resident #7's admission record revealed the facility admitted the resident on [DATE], with diagnoses that included difficulty in walking and Chronic A-fib for which the resident received anticoagulation medication therapy. Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of seven (7), which was indicative of being severely cognitively impaired. Continued MDS review revealed the facility also assessed Resident #7 as requiring extensive assistance of two (2) person for transfers and toileting. Review of Resident #7's Comprehensive Plan of Care (CCP) initiated on [DATE], revealed the facility care planned the resident as a high risk for falls with interventions which included staff being required to assist the resident to the bathroom and check on him/her every two (2) to three (3) hours and as needed, provide incontinence care as needed, and encourage the resident to ask for assistance for ambulation. Continued review revealed additional interventions included ensuring Resident #7's bed was in the lowest position as needed; his/her call light was in reach when in bed; keeping his/her room neat and clutter free; and reminding the resident of safety awareness such as locking the brakes of his/her wheelchair prior to attempting to stand or transfer, and ensure the resident wore appropriate footwear. Continued review of the CCP revealed the facility also care planned Resident #7 for ADL's with a target date of [DATE]. Review of the ADL care plan revealed the focus was for Resident #7 to have assistance with toileting, bathing, dressing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and ambulation related to generalized weakness, and his/her diagnoses. Per review of the ADL care plan, the goals included Resident #7 maintaining his/her current level of ADL functioning without a significant decline unless he/she experienced unavoidable deterioration due to the disease process. Continued review of the ADL care plan revealed interventions which included the resident might require occasional two (2) person assist with bed mobility, transfers, and toileting and it would take more staff to provide for the resident's care. Further review revealed however, no documented evidence the facility had revised Resident #7's care plan to include an increased level of supervision related to assisting the resident with toileting after his/her fall on [DATE]. Review of Resident #7's Progress Note titled, Change in Condition dated [DATE] at 10:51 AM, revealed the resident had been found sitting on his/her bottom on the floor next to his/her bed. Per review, Resident #7 stated he/she had gotten up to use the bathroom and slipped and fell on his/her buttocks. Review revealed Resident #7 had been wearing a urine-saturated brief, hospital gown and non-skid socks at the time of the fall, with a puddle of urine observed next to the resident on the floor. Continued review revealed a skin tear was noted to Resident #7's right elbow with blood present, and the Physician was notified and new orders were obtained to include oxygen for the resident and continued monitoring of him/her. Review of the hospital Medical Records dated [DATE], revealed Resident #7 had fallen on [DATE] at the nursing home where he/she resided and was complaining of severe pain to his/her right hip area. Continued review revealed Resident #7 stated he/she had fallen from a standing position with no assistive device. Per review of the hospital medical records, observation revealed Resident #7's right elbow was bandaged, without complication and limited ROM to his/her right hip. Further review revealed Resident #7 was diagnosed with a displaced right femoral neck fracture, and the Physician's recommendation was for the resident to be transferred to a higher level of care for Orthopedic evaluation. In addition, review revealed Resident #7 underwent right hip hemiarthroplasty for a right hip fracture on [DATE], and the resident was discharged back to the facility status post mechanical fall on [DATE]. Review of Resident #7's Progress Notes dated [DATE], [DATE], and [DATE] revealed the resident also sustained falls on those dates. Review of the [DATE] Progress Note revealed Resident #7 injured his/her head, with a raised area to the left side of his/her head with tenderness to touch noted. Observation of Resident #7 on [DATE] at 10:27 AM, revealed the resident lying on his/her bed with no nonskid socks on, his/her supplemental nasal oxygen (O2) tubing lying on floor, and the call light lying on the floor under the bed. Interview with Resident #7, at the time of observation, revealed the resident was alert and stated it had been a while since staff checked on him/her. Resident #7 stated [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices necessary to prevent accidents for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #7 and #8). 1. The facility assessed Resident #1 as at risk for falls and care planned the resident to require physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs) to include transfers and walking in his/her room. On [DATE], the facility provided a bedside commode for Resident #1's toileting; however Physical Therapy and Occupational Therapy assessed the resident to require Contact Guard Assistance (CGA), which indicated the resident needed one (1) to two (2) staff to have hands-on the resident's body to assist with steadying the resident. The resident's care plan revealed he/she was encouraged to press his/her call light for staff's assistance; however, interviews revealed Resident #1 often transferred from his/her bed to the bedside commode without staff's assistance. The facility failed to revise the resident's care plan to supervise/monitor for the resident's refusals to utilize his/her call light for assistance and failed to provide the resident education related to his/her risk versus benefits should the resident experience a fall while on anticoagulants, to prevent the resident from falling. On [DATE], while toileting himself/herself on the bedside commode, Resident #1 fell and sustained injuries which resulted in his/her death. 2. The facility assessed Resident #2 as at risk for falls, and initiated a care plan on [DATE], for the resident's risk. The facility's care plan for Resident #2 revealed interventions which included keeping the resident's bed in the lowest position. However, on [DATE], Resident #2 fell from his/her bed while the bed was in the highest position and sustained a large right subdural hematoma; a left temporal, subarachnoid hemorrhage; and fracture of the right temporal bone. Resident #2 expired on [DATE], due to the trauma sustained related to the fall. 3. The facility admitted Resident #3 on [DATE], with diagnoses that included Atrial Fibrillation which required anticoagulation therapy. The facility assessed Resident #3 as a high risk for falls due to a history of falls and decreased safety awareness. However, the facility failed to care plan Resident #3 for the potential for harm should the resident sustain a fall while on anticoagulant therapy. Resident #3 experienced a fall from his/her bed on [DATE], and again on [DATE], when he/she fell out of his/her wheelchair hitting his/her head on the floor. After the fall, the facility transferred Resident #3 to the hospital, where the resident was diagnosed with a severe subarachnoid hemorrhage and placed on trauma alert due to the fall. 4. The facility admitted Resident #7, on [DATE], with diagnoses that included Chronic Atrial Fibrillation, with use of anticoagulation therapy (blood thinner). The facility assessed Resident #7 to be a high risk for falls and care planned the resident for the fall risk. However, the facility failed to care plan Resident #7 for the use of blood thinner medication, and the potential for serious outcomes if he/she sustained a fall while on the medication. The facility care planned Resident #7 for staff to check on and assist the resident to the bathroom every two (2) to three (3) hours. However, on [DATE], at approximately 10:51 AM, Resident #7 experienced an unwitnessed fall with major injury while attempting to toilet on his/her own. Resident #7 was sent out to the hospital with complaints of severe right hip pain and admitted . Resident #7 was diagnosed with a displaced right femoral neck fracture and underwent a right hip hemiarthroplasty. Resident #7 returned to the facility on [DATE]. Review of the facility's Event Reports revealed the resident fell again on [DATE], [DATE], [DATE], with no injuries reported. However, following the four (4) falls there was no documented evidence the facility updated Resident #7's care plan with additional interventions, to include interventions for the need of additional supervision. 5. The facility assessed Resident #8 as a high risk for falls on admission, and to require one (1) staff person's assistance to toilet and transfer. Resident #8 sustained four (4) falls from [DATE] to [DATE]. On [DATE] at approximately 11:30 PM, staff found the resident lying on the floor by his/her bed on his/her right side. On [DATE], the resident complained of pain and an X-ray was ordered; the resident had a closed fracture of the 4th and 5th metatarsal bone. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care. F689 Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement: F865, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt all at a Scope and Severity (S/S) of K'. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on [DATE], prior to exit on [DATE]. The findings include: Review of the facility's policy titled, Chapter 7: Abuse Prevention Managing Incidents and Fall, undated, revealed the following information: provide timely analysis of falls/incidents to determine possible contributing factors and/or trends; develop and implement reasonable and appropriate action plans and resident specific care plans to identify interventions reducing the potential of future falls/incidents. Further review revealed falls and incident management also included: identifying high-risk residents and ensuring complete assessment and care planning and communicating the plans to appropriate staff through orientation, in-services, staff meetings, shift report, and care planning. Review of the facility's policy titled, Falls Management, undated, revealed the Interdisciplinary Team (IDT) was to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Per review, residents were to be assessed for fall risks as part of the nursing assessment process, to include assessing and reviewing residents' risk factors for falls and injuries upon admission, with a significant change in condition, or after a fall. Policy review revealed its purpose was to reduce the risk for falls and minimize the actual occurrence of falls, address any injury, and provide care after a fall. Review revealed the facility was to implement goals and interventions with the resident/family included in the interdisciplinary plan of care (IPOC) based on individual needs. Further review revealed the facility was to communicate interventions to the caregiving team, review and revise the IPOC at subsequent IPOC meetings, and educate the resident and family as indicated. In addition, policy review revealed for fall injury prevention and after a fall staff should assess the resident and immediately implement appropriate measures to prevent injury. Review of the facility's policy titled, F869, Accident and Incident Guidelines, undated, revealed the Director of Nursing (DON) and the Interdisciplinary Team (IDT) were to review the incident/accident at the next Clinical Quality Improvement (CQI) meeting to follow up incident documentation that would occur for the next seventy-two (72) hours to ensure no latent injury surfaces. Continued review revealed Further review revealed the resident's care plan was to be addressed to ensure that any needed points of focus had measurable goals with appropriate interventions in place and the Certified Nurse Aide (CNA) Kardex (CNA care plan) were also be updated as indicated to reflect the current care plan. 1. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Congestive Heart Failure (CHF), History of Myocardial Infarction (heart attack) and Atrial Fibrillation. Review of Resident #1'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 thirteen (13) which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed Resident #1 required extensive physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs) to include bed mobility, transfer and walking in room, and one (1) person limited physical assistance with other ADLs. Further review revealed the facility assessed Resident #1 to require staff's assist with weight-bearing support for the guided maneuvering of limbs or other non-weight-bearing assistance for transfers, walking in his/her room, and for toilet use. Review of the Comprehensive Care Plan dated [DATE], revealed the facility care planned Resident #1 as at risk for falls related to: deconditioning; gait and balance problems; impaired range of motion; and loss of smooth joint movement. Continued review of the falls risk care plan revealed the goal stated Resident #1 would have a safe environment and interventions which included: partial bed rails up with cane rails (a handle attached to the bed) for use in bed as an enabler for bed mobility; gather information on past falls and attempt to determine the root cause of the fall(s); anticipate and intervene to prevent (fall) recurrence; be sure call light was within reach and encourage the resident to use it for assistance as needed. Further falls care plan review revealed the interventions also included: staff to respond promptly to all requests for assistance; and to anticipate and meet the individual needs of the resident. However, the facility failed to ensure the resident was care planned for increased supervision, when the resident was known to ambulate without staff assistance and failed to care plan for the resident's risk versus benefits should the resident experience a fall while on anticoagulants (a blood thinner). Review of Resident #1's Physician's Order, dated [DATE], revealed the resident was ordered to be administered a 5 milligram (mg) tablet of Coumadin (a blood thinner), in the evening every Tuesday, Thursday, and Saturday. Review of the manufactures recommendation for the drug, last updated [DATE], revealed [residents] should avoid any activity or sport that may result in traumatic injury. Review of Resident #1's Occupational Therapy (OT) Summary dated [DATE], revealed the resident would safely perform toileting tasks using a bedside commode (BSC) with Contact Guard Assist (having staff provide one (1) to two (2) hands-on the resident's body and assist with steadying the resident to help with balance). Review of Resident #1's Physical Therapy (PT) Discharge Summary dated [DATE] revealed the resident required Contact Guard Assist (CGA) when being assisted to his/her bedside commode. Review of Resident #1's Progress Note dated [DATE] at 12:05 AM, revealed the resident had sustained a serious fall and had been found face down on the floor. Continued review of the note revealed Registered Nurse (RN) #1 documented Resident #1 got up to use the bedside commode (BSC) and fell . Per review, Resident #1 had a cut above his/her eye and swelling was noted. Further review revealed the Physician, and family were notified, and EMS (Emergency Medical System) transported Resident #1 to the hospital. Review of the facility's initial investigation, dated [DATE], completed approximately forty-four (44) days after the resident's fall, revealed the facility investigated Resident #1's fall (which occurred on [DATE] and resulted in major injury to the resident) and subsequent death after Adult Protective Services (APS) notified staff of the allegation of abuse and/or neglect on [DATE]. Continued review revealed the Administrator reported the allegation to the State Survey Agency (SSA) on [DATE], conducted the investigation, and sent the five (5) day follow-up of the findings to the SSA on [DATE]. Additionally, review of the facility's investigation information revealed on [DATE] at approximately 11:30 PM to 12:05 AM, Resident #1 was found lying face down on the floor in his/her room. Per review, Resident #1 reported he/she got up out of bed to use the bedside commode and fell . Review of the investigation revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of the investigation further revealed Resident #1's call light had been in reach; however, the resident had not turned his/her call light on. In addition, review of the investigation revealed there were no witnesses to Resident #1's fall, and his/her bedside commode was listed as an environmental hazard that was present. Review of the Emergency Medical Service (EMS) Run Sheet, dated [DATE], revealed the County EMS had been contacted by the facility on [DATE], at approximately 12:01 AM for an incident that involved a fall. Continued review revealed EMS Crew #1 arrived on scene at approximately 12:25 AM and found Resident #1 lying prone (face down) on the floor, with excessive facial bleeding and his/her eyes swollen shut. Per review of the Run Sheet, EMS Crew #1 noted Resident #1 stated he/she had been trying to get to the bathroom and was on a blood thinner. Further review revealed Resident #1 was transferred to the ambulance where he/she required suctioning to clear his/her throat of blood. The resident began vomiting blood. In addition, review revealed EMS Crew #1 documented due to Resident #1's head trauma and difficulty in maintaining the resident's airway free of blood, a request for ALS (Advanced Life Support) was made to assist with care, as well as, Air Medical for flight transfer to a Level One (1) Trauma Center. Review of the trauma hospital medical records dated [DATE], revealed Resident #1 arrived at 1:49 AM, and was diagnosed with Acute Respiratory Failure with Hypoxia, Open Fracture of Facial Bone due to a Fall, Closed Odontoid (second neck vertebrae) Fracture, Epistaxis (nosebleed) due to Trauma and Fall. Further review of the hospital documentation revealed Resident #1 had been non-responsive, and was transferred to the Hospice Unit, where he/she passed away the following day, on [DATE]. Review of the Death Certificate for Resident #1 dated [DATE], revealed the resident died of Acute Post-Traumatic Respiratory Failure due to complications of Blunt Force Head and Neck Trauma due to a Fall from a Standing Position. Interview with Resident #1's roommate, Resident #10, on [DATE] at 3:56 PM, revealed the resident did not recall the incident related to Resident #1's fall. Per interview, however, Resident #10 did recall how Resident #1 would take himself/herself to the bedside commode, without the staff's assistance. Interview with Resident #10 further revealed Resident #1 would get short of breath and weak a lot of times; however, the resident would still get up on his/her own but really needed staff to assist him/her. Interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 9:18 PM, revealed she had provided direct care of Resident #1 and stated the resident would call out at times requesting to be pulled up in bed. The CNA stated Resident #1 had tried to get up and go to the bedside commode by himself/herself; however, staff made a point of encouraging the resident to ask for assistance to the commode. According to CNA #2, on the night of Resident #1's fall she heard CNA #1 scream, come now, and when she got to the resident's room, she saw him/her lying halfway under his/her roommate's bed. Further interview revealed Resident #1 had blood on his/her face and on the floor by him/her. She further revealed Registered Nurse (RN) #1 and RN #3 both were at Resident #1's side taking care of the resident's injuries, applying ice packs, and taking his/her vital signs. Interview further revealed CNA #2 stated Resident #1 had a laceration to the left side of the top part of his/her eye and under his/her eye. In addition, CNA #2 stated staff could not move Resident #1 due to the unknown extent of his/her injuries and head trauma so, they placed towels down on the floor around his/her head and body. Interview with CNA #1 on [DATE] at 4:09 PM, revealed Resident #1 used a bedside commode for toileting and required staff assistance with his/her Activities of Daily Living (ADL) care. CNA #1 stated Resident #1 would sometimes ring the call bell to ask for assistance; however, the resident tried to get up and do things on his/her own, such as using the bedside commode (BSC) without assistance. Per CNA #1, staff reinforced and encouraged Resident #1 to use the call bell for assistance and encouraged the resident not to get up on his/her own. Continued interview revealed on the night Resident #1 fell , at approximately 11:00 PM CNA #1 offered to assist Resident #1 with using the BSC and to record the resident's output for the shift. She stated Resident #1 had not requested her assistance to use the bedside commode since shift change. Per interview with CNA #1, at approximately 12:00 AM to 12:05 AM, as she had started her charting in the hallway, she heard a loud noise from the area of Resident #1's room. She stated upon entering Resident #1's room, she observed the resident lying on his/her stomach on the floor, with his/her head and upper body under the roommate's bed. Further interview revealed she yelled for help and additional staff responded immediately. In addition, CNA #1 stated RN #1 immediately called for an ambulance as RN #3 provided direct care to Resident #1. Interview with Registered Nurse (RN) #1 on [DATE] at 1:34 PM, revealed she had worked at the facility for eighteen (18) years and had provided direct care of Resident #1. RN #1 stated Resident #1 required encouragement and reinforcement to use his/her call light for assistance to the bedside commode; however, not as much at night as staff knew to check on him/her routinely. Per interview, RN #1 revealed staff had been trained to monitor Resident #1 for noncompliance with assistance and to ensure the bedside commode was in the correct position at the end of his/her bed. Further interview revealed she was aware the resident was on blood thinners and often refused to press his/her call light for assistance; however, the resident was not placed on increased supervision nor did the facility discuss with the resident risk versus benefits should the resident experience a fall but should have. Continued interview, with Registered Nurse (RN) #1, on [DATE] at 1:34 PM, revealed on [DATE], at approximately 11:50 PM to 12:00 AM, while in the hallway starting her medications pass, she heard a loud noise and both she and CNA #1 went to Resident #1's room. RN #1 stated they observed Resident #1 lying on the floor on his/her stomach face down and halfway under his/her roommate's bed. Interview revealed Resident #1 had a moderate amount of blood coming from his/her nose and the resident stated, I was getting up to use the potty. Further interview revealed RN #3 and CNA #2 came to help, and they both started providing care, applying pressure and an ice pack to Resident #1's forehead laceration and to the bleeding from his/her nose. Further interview revealed RN #3 began taking vital signs and monitoring the resident while RN #1 called EMS for immediate transfer. RN #1 further stated EMS was notified at approximately 12:05 AM and made aware of Resident #1's fall and that he/she was bleeding profusely and was on Coumadin (a blood thinner medication). Interview with RN #3 on [DATE] at 10:50 AM, revealed she had been called to assist with a resident's fall (Resident #1) around 12:00 AM on [DATE]. Per interview, she was familiar with Resident #1, and that the resident required assistance; however, knew most of the time the resident got up and used the bedside commode on his/her own. RN #3 revealed Resident #1 was assessed and sent out to the hospital immediately due to the severity of his/her injuries. Continued interview revealed RN #3 did not believe Resident #1 was assessed as a falls risk, nor was any additional monitoring required. RN #3 further revealed the resident was on blood thinners and should have been educated on the risk versus benefits of experiencing a fall while on blood thinners. She stated Resident #1 only required encouragement to use his/her call light. Further interview revealed, after the fall, the RN observed Resident #1 to have facial injuries and a laceration above his/her right eye. RN #3 further stated the resident had bleeding which was coming mostly from his/her nose and nasal cavity. Interview with Emergency Medical Service (EMS) Provider #2 on [DATE] at 11:00 AM, revealed on the early morning of [DATE], he was dispatched to the facility to transport an eighty-two (82) year-old male/female due to extensive injury after a fall which included severe head trauma. EMS Provider #2 the resident had to be transferred to the local Helipad for Air Vac Medical (AVM) flight services to transfer the resident to a Level 1 Trauma Center related to his/her condition and injuries. Interview with the Director of Nursing (DON) on [DATE] at 5:20 PM, revealed residents' rights included the right to fall, and the facility had done everything it could do to prevent residents' falls. She stated Resident #1 never had a prior fall, and this was his/her first fall. Further, she stated the facility ensured the resident's safety; however, we could only do so much. Review of the facility's policy, however, revealed fall injury prevention and after a fall included staff assessment of the resident, and [staff] would immediately implement appropriate measures to prevent injury. Interviews with Certified Nursing Assistant (CNA) #1 on [DATE] at 4:09 PM; Registered Nurse (RN) #1 on [DATE] at 1:34 PM; and RN #3 on [DATE] at 10:50 AM, revealed they were aware the resident refused to utilize his/her call light to ask for assistance to toilet, when the resident required one (1) to two (2) staff to assist. Further record review revealed there was no documented evidence to support the facility care planned for the resident's increased ambulation to his/her bedside commode, without staff supervision and no documentation to support the facility discussed with the resident his/her risk versus benefits should the resident fall while on blood thinners. 2. Review of Resident #2's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses which included Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus, Anxiety Disorder and Required Need for Assistance with Personal Care. Review of Resident #2's Admission's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of ten (10), indicating the resident was moderately cognitively impaired. Continued review revealed the facility assessed Resident #2 to require extensive assistance of two (2) plus persons for physical assistance with bed mobility, transfers, and locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of Resident #2's Comprehensive Care Plan initiated [DATE], revealed the resident was at risk for falls related to impaired balance and mobility, and use of psychotropic medications. Continued review revealed Resident #2 was to be free from falls and fall-related injuries with interventions which included: keeping the resident's bed in the lowest position; anticipating the resident's needs; assisting with mobility and transfers; maintaining a clutter-free environment; placing the call bell within reach; and observing for side effects of medications. Further review of the care plan revealed no documented evidence the facility discussed with Resident #2 his/her risk versus (vs.) benefit related to accidents, should he/she have a fall while on blood thinners (Plavix). Additionally, review of the care plan revealed no documentation to support the facility care planned Resident #2 for his/her history of Urinary Tract infections (UTIs) with mental status changes, to include the resident raising his/her bed from the lowest to the highest position when he/she exhibited signs of confusion, which required additional supervision and monitoring to prevent accidents. Review of the facility's Change in Condition Assessment for Resident #2 dated [DATE] at 12:37 PM, revealed the resident's condition change was, Altered Mental Status with Behavioral Symptoms (agitation, psychosis, diarrhea, nausea, and vomiting). Per review, Resident #2 had been experiencing Altered Mental Status Behavioral Symptoms to include diarrhea with nausea and vomiting symptoms which started on [DATE]. Continued review revealed the symptoms also included: increased confusion; cussing and hitting at staff; talking with different voices and had a large amount of green bile noted from vomit. Further review revealed Resident #2's increased confusion persisted, and the Medical Provider was notified on [DATE] at 12:43 PM. Additionally review revealed an order was obtained to send Resident #2 to the emergency room (ER) for evaluation and treatment. Review of the facility's Change in Condition Assessment for Resident #2 dated [DATE] at 7:30 PM, revealed the resident sustained a fall. Review revealed Resident #2 had: bleeding; suspected serious injury (Fracture); Contusion with Wound on the face above the right eye; and altered and sudden change in level of consciousness and responsiveness. Continued review revealed the Medical Provider had been notified, and an order was obtained to send the resident to the ER for evaluation and treatment. Review of Resident #2's Progress Note dated [DATE] at 7:40 PM, signed by Licensed Practical Nurse (LPN) #1, revealed the resident had been found on the floor parallel with his/her bed, wearing a gown, brief, and with a Foley catheter in place. Review revealed Resident #2 had been incontinent of bowel at the time of the fall. Continued review revealed Resident #2 had just returned from the ER, after being evaluated for a change in behavior and cognition, approximately thirty (30) minutes prior to the incident. Further review revealed Resident #2 had been placed in his/her bed upon return from the ER, with the bed placed in the lowest position. Per review of the Note, revealed Resident #2's call light and remote were placed within reach. Further review revealed however, at the time of the resident's fall, his/her bed was found up in the highest position and the call light on the floor next to the resident. In addition, review further revealed Resident #2 had a significant amount of blood noted from a laceration above the right eye approximately ten (10) centimeters in length. Review of Resident #2's Event Summary Report, dated and signed by the Director of Nursing (DON) on [DATE], revealed at approximately 7:30 PM, the resident was found lying on the floor parallel with his/her bed. Continued review revealed Resident #2 had just returned from the ER, where he/she was evaluated for a change in mental status and behavior symptoms, approximately thirty (30) minutes prior to the fall. Further review revealed Resident #2 had been diagnosed with a UTI while at the ER visit, prior to the fall, and Intravenous (IV) antibiotics had been given to him/her. Review of the Facility Fall Investigation for Resident #2 dated [DATE], revealed the resident's bed was noted to be waist high, (in the highest position) and the call light lying next to the resident on the floor in reach; however, was not on. Continued review revealed Resident #2 had been wearing a gown, and a brief at the time of the fall. Per review, Resident #2 had blood noted from a laceration approximately ten (10) centimeters (cm) to the right side of his/her face, above the eye. Further review revealed the fall had been unwitnessed with major injuries. Additional review revealed, the required State Agencies had not been notified due to not being necessary or feasible. Continued review of the Facility Fall Investigation documentation revealed no documented evidence the facility performed a root cause analysis of Resident #2's fall. Per review, the facility noted Resident #2 fell from his/her bed after returning from the ER and sustained a head injury. Review further revealed no documentation to support the facility had taken corrective action. Review of the trauma hospital's medical record for Resident #2 dated [DATE], revealed the resident arrived at the Level 1 Trauma Center via helicopter on [DATE] at 9:25 PM, status post fall. Continued review revealed Resident #2 was reportedly found down in a large pool of blood, and there was no report of the resident striking his/her head on objects aside from the floor. Per review, Resident #2 was life-flighted (transported by helicopter) to the Trauma Center, intubated and had posturing (indicative of severe brain or spinal injury). Review revealed Resident #2's injuries included a large right Subdural Hematoma status post right craniotomy on [DATE], diffuse Subarachnoid Hemorrhage (SAH), Facial Lacerations, Right Face and Front temporal Hematoma, Right Femoral Neck Fracture, and Left Corneal Laceration status post repair on [DATE]. Further review revealed a Tracheostomy was placed on [DATE] per the family's wishes, and Resident #2 died on [DATE], due to trauma related to the fall. Review of the Autopsy Report for Resident #2 dated [DATE], revealed the preliminary diagnoses included: Blunt force injuries to the head sustained in a fall; Fracture of Right Temporal Bone; Right Temporal Extradural and Thin Subdural Hemorrhages; Left Temporal Subarachnoid Hemorrhage. Continued review of the Autopsy Report revealed Resident #2 had delayed death status post-medical intervention, and toxicology was not performed due to the duration of the hospital stay. Further review of the report revealed the focused exam information noted Resident #2 had experienced an internal bleed of the head. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 11:50 AM, revealed Resident #2 required total assistance and had returned from the hospital at approximately 7:10 PM on [DATE]. CNA #1 stated at approximately 7:15 PM, LPN yelled for help due to Resident #2 being found lying on the floor. Continued interview revealed CNA #1 did not witness Resident #2's fall and had not been fully aware of the resident's care plan interventions, specific to falls. Further interview revealed however, she felt all residents were at risk for falls and should be monitored and reviewed to protect the resident from injury. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:12 AM, revealed Resident #2 had a history of Urinary Tract Infections (UTIs) with mental status changes. She further stated the resident should have been care planned for his/her mental status changes and should have been monitored more closely. LPN #1 further revealed that on [DATE], Resident #2 was transferred to the hospital due to his/her mental status changes. She stated Resident #2 returned to the facility between 7:00 PM and 7:10 PM on [DATE], the same day, and was anxious and agitated. Per interview, RN #1 asked LPN #1 to hang intrave [TRUNCATED]

Based on interview, record review, review of the facility's policy and Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration's failure to follow its policies in preventing falls and ensure the safety of residents assessed as at high risk for falls resulted in injury for five (5) of nine (9) sampled residents, Residents #1, #2, #3, #7 and #8. Interviews with the Administrator, Director of Nursing (DON), and Minimum Data Set (MDS) Coordinator revealed they participated in the facility's Interdisciplinary Team (IDT) meetings. However, the IDT failed to follow the facility's falls policy to include: analysis of the contributing factors that lead to residents' falls; and developing appropriate action plans specific to those residents. The IDT further failed to ensure residents assessed to be at risk for falls were care planned with necessary interventions according to their assessed needs. The facility's failure to be administered in a manner which enabled effective use of its resources has caused or is likely to cause serious harm, impairment, or death of a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 11/23/2022, and was determined to exist on 11/06/2021, in the areas of 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices (F689); at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Care Plan Timing and Revision (657); at 42 CFR 483.70 Administration (F835); and at 42 CFR 483.75 Quality Assurance and Performance Improvement, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt (F865) all at a S/S of K. The facility was notified of the Immediate Jeopardy on 11/23/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 12/05/2022, with the facility alleging removal of the Immediate Jeopardy on 11/30/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 11/30/2022, prior to exit on 12/08/2022. (refer to F656, F689, and F865) The findings include: Review of the facility's Job Description for the, Administrator, undated, revealed the Administrator led and directed the overall operations of the facility in accordance with residents' needs, federal and state government regulations, and company policies to maintain quality care for residents while achieving the facility's business objectives. Per review, the Administrator's essential job duties included conducting regular rounds to ensure staff addressed residents' needs and to monitor operations of all departments. Continued review revealed the Administrator ensured adequate staffing through the development of recruitment sources, and managed turnover through appropriate selection, orientation, training and staff education. Review revealed additional roles and responsibilities of the Administrator included recognizing potential hazards and monitoring personnel to ensure safety procedures were followed. Further review revealed the Administrator ensured the understanding of and compliance with all rules regarding residents' rights. In addition, the Administrator was to work with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments. Review of the facility's policy entitled, Managing Incidents and Fall, undated, revealed all residents would benefit from a safe environment and an individualized plan of care. Review of the policy revealed the facility was to provide timely analysis of falls/incidents to determine possible contributing factors and/or trends. Continued review revealed the facility was also to develop and implement reasonable and appropriate action plans and resident specific care plans in order to identify interventions which reduced the potential of future falls/incidents. Further review revealed the facility was to: identify high-risk residents; ensure complete assessment and care planning for residents; provide for analysis of underlying systems issues and develop performance improvement plans, and communicate the plans to appropriate staff through orientation, in-services, staff meetings, shift report, and care planning. Interview with Certified Nursing Assistant (CNA) # 6 on 11/21/2022 at 10:42 AM, revealed she was unaware of Resident #7's care plan, and stated she did not know the resident was a falls risk. CNA #6 revealed she should have used the Kardex (CNAs care plan) to care for Resident #7. Additionally, she stated it was important to know residents' care plan interventions to prevent a fall because it could cause a safety concern, and added the resident could get hurt. Interview with Registered Nurse (RN) #1 on 11/01/2022 at 3:48 PM, revealed when a resident had a change of condition, she would not revise the resident's care plan to implement additional interventions. RN #1 revealed she waited until she notified the Director of Nursing (DON) or Minimum Data Set (MDS) Coordinator of resident's change in condition. Further interview revealed it was important to revise residents' care plans with immediate changes, related to falls, to prevent an injury. Interview with the Minimum Data Set (MDS) Coordinator on 11/21/2022 at 2:50 PM, revealed he was part of the IDT that went over residents' falls, the day after residents experienced a fall. He stated it was the responsibility of the direct care nurse to update/revise residents' care plans when a resident had a change of condition and/or fall. Continued interview revealed it was important for the direct care nurse to revise the residents' care plans to ensure the safety of the residents. Further interview revealed the IDT would review all interventions put in place by the direct care nurse, and monitor to ensure the interventions were effective. Interview further revealed however, he was unaware of any auditing process or tool the facility utilized to ensure care plan revisions were implemented and/or effective. Interview with the Director of Nursing (DON) on 10/26/2022 at 11:26 AM, revealed when a resident sustained a fall, nursing completed an incident report, investigated the incident and notified the guardian and Physician. She stated the Interdisciplinary Team (IDT) reviewed the incident reports for residents' falls the next morning, and reviewed the residents' care plans and interventions and implemented additional interventions if needed, to include a therapy screen if the resident was not already receiving therapy. Continued interview revealed the IDT met for three (3) days after a resident's fall to follow up and communicate any concerns. Interview further revealed seven (7) days after the fall, the IDT then collaborated and determined if the interventions implemented were working and were appropriate. Further interview revealed however, the facility's IDT did not audit residents' care plan interventions to ensure the effectiveness of the interventions. Interview with the Administrator on 11/21/2022 at 4:05 PM, revealed the facility utilized and implemented several fall resources, such as utilizing the falls risk assessment and following its falls management procedures. She stated the IDT and Medical Director were involved with developing a plan to reduce the number of residents' falls within the facility. Further interview revealed however, the facility did not audit or monitor to ensure the interventions implemented were effective. Interview with the Regional Nurse Consultant (RNC) on 12/08/2022 at 7:13 PM, revealed it was the Administrator's responsibility to watch, identify patterns, analyze, and implement changes based on the facility's findings for improvement. He stated the IDT were to collaborate and figure out what the root cause of the falls were, and then decide what action plan to initiate. Further interview revealed the RNC served as part of the team to provide education/training for all staff regarding the care plan process, function, timing, how to retrieve, and ensured the audit information was taken to share with the facility. ****The facility provided an acceptable Immediate Jeopardy Removal Plan on 12/05/2022, alleging removal of the Immediate Jeopardy on 11/30/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 11/28/2022, corrective action(s) were accomplished for those residents found to have been affected by the same deficient practice (Resident's #1, #2, #3, #7, and #8): (a) Resident #1 no longer resided at the facility; Resident #2 no longer resided at the facility; and Resident #3 no longer resided at the facility. (b) On 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse related to the resident's use of anti-coagulant therapy as related to falls. Resident #7's care plan was revised on 11/27/2022, by the RN Weekend Supervisor related to the resident's current one-on-one (1:1) supervision. (c) On 11/21/2022, the Charge Nurse revised and updated Resident #8's care plan to include appropriate interventions to prevent falls related to: the resident's continued refusal to wear a mobilizer boot on his/her right lower extremity; and refusing wear of non-skid slippers. Resident #8's care plan was updated to include a new mattress being placed on his/her bed as the resident stated he/she had slid off the mattress which caused his/her fall. In addition, Resident #8 had the non-compliant care plan updated on 11/21/22, by the MDS Coordinator. (d) On 11/28/2022, the facility implemented the MDS Coordinator continuing to monitor the falls care plans and update the care plans based on the resident's Fall Risk assessments completed on admission, re-admission, with a change of condition, a fall or quarterly. 2. On 11/28/2022, an audit was conducted of residents at risk for falls, and the facility identified and implemented corrective actions for residents residing in the facility and at risk for falls with the potential to be affected by the same deficient practice: a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. (b) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit of any residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. The audit included ensuring those falls were reviewed to ensure (as much as possible, considering the length of time since the fall), that they had been investigated and that a root cause had been defined for residents that had a fall in the last three (3) months. (c) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure appropriate assessments had been done post fall and that therapy screened the residents post fall. Additionally, the audit included ensuring the residents' care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure that Action Plans had been implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. (e) On 11/28/2022, the facility implemented a corrective action for residents who had a fall to ensure those residents were reviewed in the weekly Falls Meeting until the IDT decided that the residents' falls had been managed and they were no longer at HIGH RISK for falls. In addition, some residents might remain on the Falls Meeting list indefinitely for long-term monitoring purposes and based on their Falls Risk score. All falls were to be reviewed at the next daily, Monday through Friday (M-F) morning Clinical Quality Indicator (CQI) meeting following the fall to ensure that all post fall protocols were followed. (f) Beginning 11/28/2022, the facility implemented an additional corrective action for the DON/Unit Manager to monitor all falls post fall as well as, at the Falls Meetings weekly. In addition, the Nurse Consultant for the facility would be notified either in person or remotely of any fall sustained by any resident to offer guidance and input. 3. Beginning 11/23/2022, the facility additionally implemented corrective measures to promote systemic changes that ensure the deficient practice would not recur (a) On 11/28/2022, the facility implemented a systemic schedule that all falls would be reviewed at the next daily, M-F CQI meeting following the fall at this time, it would be determined if all post fall protocols were followed. Any concerns would be addressed. (b) Beginning 11/23/2022, the Administrator/DON/UM, with input from the RNC conducted an in-service training for all staff that reviewed: the Falls Policy; what to do if you (in your role) witness a resident who had fallen; Nurses: what to do when a resident fell ; why it was important to identify the root cause of a fall; what are FALL INTERVENTIONS; care plans/CNA's assignment sheets related to falls; action plans rolled out with a focus on falls; questions/answers. (c) Beginning 11/23/2022, the Administrator/DON/UM ensured staff knowledge was measured by a POST TEST performance that required 100% accuracy of the answers to pass. Any staff who failed to comply with the points of the in-service would be further educated and/or progressively disciplined as indicated. In addition, no staff would work prior to receiving the in-service after 11/28/22, this included any newly hired staff, agency staff, prn staff or any staff on any type of leave or vacation. 4. On 11/28/2022, the facility implemented a monitoring system of the corrective actions to ensure the deficient practice did not recur, (i.e., what Quality Assurance Program would be put into place and by what date the systemic changes for each deficiency would be completed). (a) Beginning 11/28/2022, the DON/Unit Manager were to review all falls at the next daily CQI meeting held M-F, to ensure that all post fall protocols were followed per policy and regulation. (b) On 11/28/2022, the daily CQI meeting was held and consisted of the Administrator, DON, UM, MDS, SSD, and Rehab Director and all residents who were at HIGH RISK for falls were to be discussed at the weekly Falls Meeting, until the IDT, decided that the residents' falls had been managed and the resident was no longer a HIGH RISK for falls. (c) On 11/28/2022, the results of the falls monitoring from the daily (M-F) CQI meetings as well as the weekly Falls Meetings were to be presented by the DON/Unit Manager at the weekly then monthly QAPI meetings. Any concerns or patterns were to be addressed and identified. (d) On 11/28/2022, if needed, an Action Plan/PIP was to be written by the QAPI Committee with input from the Regional Team. Any written Action Plan/PIP was to be monitored weekly by the Administrator until resolved. (e) On 11/28/2022, the facility also implemented a member of the Regional Team to attend the QAPI meetings either in person or remotely weekly, then monthly for three (3) months. The Regional Team members were to serve as a reference and additional oversight. The facility's QAPI Committee Members include: the Administrator, DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping/Laundry Supervisor, RVP/RDO/RNC/MDS Consultant (might attend if present), Pharmacy Consultant/Dietician (might attend if present), and the Medical Director/Nurse Practitioner. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 11/30/2022 1. (a) Review of the facility's documentation and medical record review revealed Resident #1, Resident #2, and Resident #3 no longer resided at the facility. (b) Review of the facility's documentation and care plans revealed on 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse to reflect the resident's use of ant-coagulation therapy as related to falls, and the care plan had been revised on 11/27/2022, by the RN Weekend Supervisor related to resident's current one-on-one (1:1) supervision. Continued review of Resident #7's care plan revealed resident centered goals for fall prevention and interventions in place as alleged. Observation of Resident #7 on 12/07/2022 at 9:13 AM and 12/08/2022 at 2:45 PM, revealed the resident in a room across from the nursing station, resting in a low bed with neon tape on the call light and 1:1 supervision, as care planned. Interview on 12/08/2022 at 4:09 PM, with the RN Weekend Supervisor revealed she had revised and updated Resident #7's care plan on 11/27/2022, related to 1:1 supervision. (c) Review of Resident #8's care plan revealed revisions were made to include appropriate interventions to prevent falls including the resident's refusal to: wear a mobilizer boot on his/her right lower extremity and non-skid slippers, and new mattress applied to his/her bed. In addition, review of Resident #8's care plan revealed a non-compliant care plan updated on 11/21/22, by the Charge Nurse and MDS Coordinator. Observation of Resident #8 on 12/07/2022 at 09:24 AM, revealed he/she was resting in a low bed with a new mattress in place, and wearing non-skid socks. (d) Review of the facility's documentation and interview with the Unit Manager (UM) on 12/08/2022 at 09:42 AM revealed she and the MDS Coordinator reviewed and updated the falls care plans based on the residents Fall Risk assessments completed upon admission, re-admission, quarterly, change of condition, or a fall. The DON was not available for interview. 2. (a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. Interview with UM for both units on 12/08/2022 at 9:42 AM revealed she and the DON and MDS conducted audits to ensure all residents had falls assessments completed in the last quarter, with any resident found to be high risk for falls receiving updates to their care plan. She further stated they also looked back 90 days to 08/22/2022 to determine that the residents who fell had correct interventions in place, consistent with the cause of the fall. The DON was not available to to interview due to illness and the MDS Coordinator was not available due to having surgery. (b) Review of the facility's documentation of residents at risk for falls and care plan audits dated 11/28/2022 through 12/06/2022, revealed the audits were completed as alleged of residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. Review of the facility documents additionally revealed those residents falls had been investigated and a root cause analysis had been identified with planned interventions implemented and monitored. Interview with the UM on 12/08/2022 at 09:42 AM revealed she and the MDS coordinator completed fall care plan audits including a lookback timeframe of three (3) months, from 08/22/2022. (c) Review of residents' Electronic Medical Record (EMR) review revealed assessments had been completed post fall and therapy had screened residents post fall. Continued review revealed the care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) Review of the facility's audit tools and documentation revealed the DON, UM, and MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview with the UM on 12/08/2022 at 09:42 AM revealed she, the DON and MDS Coordinator completed facility audits across the facility to ensure the action plans were implemented. (e) Interview with UM on 12/08/2022 at 9:42 AM revealed the QAPI team had been through every residents' record for fall risk and anticoagulant, and have added to care plans for bleeding risk and they process falls everyday. Further interview revealed residents who have had falls were reviewed during weekly falls meeting and continued until determined they were no longer high risk or if high risk continued, those residents would continue to be reviewed long term Interview with Administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview also revealed continued monitoring for residents with high risk for falls at weekly meeting. Review of the facility's CQI meeting sign in sheet and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meetings included discussion and review of residents' falls post fall as alleged, with the DON/Unit Manager as alleged. Interview on 12/08/2022 at 7:33 PM, with the Administrator revealed residents' care plans were revised immediately for antibiotic, skin concerns or any recent falls. The Administrator stated for the residents' comprehensive care plans, the facility utilized a tool's form, which included updated physician's orders. She further stated the managers for the unit would bring the tool to CQI to make sure the residents' care plans were revised or amended with actions discussed as needed. (f) Interview with administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview further revealed the DON and UM were monitoring falls on a weekly basis for four (4 ) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and this would be reviewed by regional staff. Interview on 12/08/2022 at 7:13 PM, the RNC revealed he had been providing direct oversight as alleged. 3. (a) Interview on 12/08/2022 at 9:42 AM, with the UM revealed beginning 11/28/2022, during the daily (M-F) CQI meeting, falls were the designated topic with daily discussion and review to determine if all post fall protocols were followed, and all concerns were addressed. (b) Review of the facility's, In-Service Falls Education Record revealed beginning 11/23/2022, the education had been provided as alleged for all staff regarding the Falls Policy; what to do if staff witnessed a resident who had fallen; for Nurses on what they should do when a resident fell ; why it was important for staff to identify the root cause of a fall; what the fall interventions were; review and update of care plans/CNA's assignment sheets related to falls; and action plans rolled out with a focus on falls. Further review revealed the Administrator, DON, and UM, with input from the RNC, conducted the in-service training for all staff. Interview on 12/08/2022 at 4:09 PM with RN #2; at 4:58 PM with LPN #1; at 4:35 PM with CNA #4, and at 6:42 PM with RN #3 and CNA #2 revealed they had been provided the education as alleged and had taken a test afterwards. (c) Review of the facility's post-tests information for the education provided for staff in all departments and the IDT team revealed all had taken the test and scored 100% as alleged. Interview on 12/08/2022 at 10:28 AM, with the HR Director revealed the education had been provided along with the POST TEST and requirement of 100% accuracy to pass the test. Continued interview revealed no staff worked prior to receiving the in-service after 11/28/2022, which included any newly hired staff, agency staff, prn (as needed) staff or any staff on any type of leave or vacation as alleged. Further interview revealed the education had been provided by the Administrator, DON, and UM with input and participation from the RNC. 4. (a) Review of the facility's CQI meeting sign in sheets and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meeting the DON/Unit Manager reviewed and discussed the post fall protocols being followed as per policy and regulation as alleged. Review of the facility's QAPI sign-in sheet and corresponding agenda dated 11/28/2022, revealed the meeting discussion included but not limited to the facility's system wide corrective actions implemented to ensure the deficient practice did not recur and date the systemic changes for each deficiency would be completed. Review of clinical records of sampled residents and training record review revealed the trainings were consistent with the removal plan. Review of QAPI documentation revealed membership, attendance, content and goals consistent with stated intent. Additional review revealed QAPI committee consisted of the Administrator, Director of Nursing (DON), Unit Manager (UM), Minimum Data Set (MDS), Business Office Manager (BOM), Social Service Director (SSD), Dietary Manager, Directors of Activities, Rehabilitation Director, Maintenance, Housekeeping/laundry supervisor, and the Medical Director/Nurse Practitioner. Further review of QAPI revealed committee developed audit tool to track education and monitoring. Interview with the Business Office Manager (BOM) on 12/08/2022 9:25 AM revealed QAPI works to resolve problems facility wide such as safety and falls. Additional interview revealed QAPI reviewed new tools for safety and fall prevention, and also discussed the two (2) falls for IJ at the last QAPI meeting. Interview with the UM on 12/08/2022 at 9:42 AM revealed the QAPI team has been through every resident record for fall risk and use of anticoagulant, and have added to care plans for bleeding risk. Interview revealed the last QAPI was this morning and they process falls everyday. (b) Review of the facility's CQI meeting sign in sheets and corresponding agendas revealed a CQI meeting was held on 11/28/2022, as alleged with the Administrator, DON, MDS, SSD, Unit Manager (UM), and Rehab Director. Continued review revealed it was determined all residents assessed as at HIGH RISK were to be discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the CQI information through 12/06/2022, revealed the members continued discussion of the same topics. Interview on 12/08/2022 at 11:23 AM with the SSD; and at 11:55 AM with the Rehab Director revealed they had participated in the daily CQI meeting, starting on 11/28/2022, discussion of audit reports of residents who were at HIGH RISK for falls which was discussed at the weekly Falls Meeting. Further interview revealed the review and discussion of HIGH RISK for falls residents continued in the weekly Falls Meeting until the IDT decided the residents' falls had been managed and the residents were no longer a HIGH RISK for falls. (c) Review of the facility's QAPI meeting sign in sheets and corresponding agendas revealed beginning on 11/28/2022, revealed the DON/Unit Manager (UM) presented the results of the falls monitoring from the daily (M-F) CQI meetings and Falls Meetings to the QAPI Committee. Continued review revealed it was determined all residents assessed as at HIGH RISK were discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the QAPI meeting information through 12/06/2022, revealed the DON/UM continued presenting and discussing of the same topics. Interview with the UM on 12/08/2022 Interview with the Administrator on 12/08/2022 at 7:33 PM revealed the DON and UM were monitoring falls on a weekly basis for four (4) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and would be reviewed by regional staff. (d) Review of the facility's audit tools revealed the DON/UM/MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview on 12/08/022 at 7:33 PM, with the Administrator revealed results of the falls audit/monitoring were being reviewed in the CQI meetings as well as the weekly Falls Meetings, and if an Action Plan/PIP was needed the QAPI Committee would write it with input from the Regional Team. The Administrator further stated she would participate in the development of any written Action Plan/PIP, and monitor it until it was determined to be resolved. (e) Interview on 12/08/022 at 7:33 PM, with the Administrator revealed the facility's QAPI Committee members included herself, the DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping and Laundry Supervisor. Continued interview revealed others who might attend if present in the facility at the time of the meeting were: the RVP, RDO, RNC, MDS Consultant, Pharmacy Consultant, Dietician, and Medical Director and/or Nurse Practitioner. Further interview revealed a member of the Regional Team had attended the QAPI Committee meetings either in person or remotely on a weekly basis. The Administrator further revealed the Regional Team's participation would decrease to every three (3) months, as determined by them, to provide additional oversight and serve as a reference for the facility. Interview on 12/08/2022 at 7:13 PM, with the Regional Nurse Consultant (RNC) revealed beginning 11/28/2022, he had been attending the facility's QAPI Committee meetings weekly either in person by remotely to provide direct oversight and act as a reference for the facility. Interview on 12/02/2022 at 6:18 PM, with the Medical Director revealed the facility held a QAPI meeting on 11/28/2022, and continued the meetings weekly. Per the Medical Director, she attended in person or remotely with the facility by phone for the QAPI Committee meetings. Continued interview revealed however, there were times when she was tied to activity at the hospital and could not attend the QAPI meetings. The Medical Director stated if she was unable to attend the meetings in person or remotely, she went over the actions discussed and taken by the QAPI Committee. Further interview revealed the facility's QAPI Committee would continue meeting weekly and move to monthly as determined by the need. In addition, the Medical Director stated during the QAPI Committee meetings there was discussion of falls and incidents, identification of the root cause, review of any removal plan, and ongoing monitoring.

Based on observation, interview, record review, and review of the facility's policy, investigations, and documentation, it was determined the facility failed to implement their Quality Assurance Performance Improvement (QAPI) program to ensure the identification of opportunities for improvement in the care and services provided to residents. The facility's QAPI process failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards of quality of care regarding performance improvement measures were sustained. As a result the facility's QAPI program failed to develop, implement, and monitor to identify issues with supervision of residents in prevention of falls. (Refer to F657, F689, and F835) The facility's QAPI program's failures allowed forty-one (41) falls to be sustained by its residents during a five (5) month look back period, with two (2) of the residents' falls resulting in death, Resident #1 and Resident #2. In addition, three (3) of the residents' falls resulted in injuries to the residents, Residents #3, #7, and #8. The facility's failure to ensure the implementation of its QAPI process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 11/23/2022, and was determined to exist on 11/06/2021, in the areas of 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices (F689); at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Care Plan Timing and Revision (F657); at 42 CFR 483.70 Administration (F835); and at 42 CFR 483.75 Quality Assurance and Performance Improvement, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt (F865) all at a Scope and Severity (S/S) of K'. The facility was notified of the Immediate Jeopardy on 11/23/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 12/05/2022, with the facility alleging removal of the Immediate Jeopardy on 11/30/2022. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 11/30/2022, prior to exit on 12/08/2022. The findings include: Review of the facility's policy titled, Quality Assurance and Improvement, undated, revealed the facility's QAPI program represented the facility's commitment to continuous quality improvement. Per policy review, the QAPI program ensured a systemic performance evaluation, problem analysis, and implementation of improvement strategies to achieve performance goals. Continued review revealed the QAPI committee's oversight responsibilities included: annual review of the facility's QAPI program; the establishment of Performance Improvement Projects (PIP) subcommittees; ensure the subcommittees had adequate resources to conduct their projects; submit findings of performance improvement (PI) projects to the chairperson which was to include a summary of QAPI project activities and findings; utilize facility data to identify opportunities to improve the facility's systems and care. Further review revealed the data might include: grievance logs; medical record reviews; skilled care claims; falls and pressure ulcer logs; treatment logs; staffing trends; incident and accident reports; and quality measures and survey outcomes. Review of the facility's, Job Description for the Administrator, undated, revealed the Administrator was responsible for the facility's Quality Assurance (QA) Program. Further review revealed the Administrator was to identify and participate in the process improvement initiatives which would improve the residents' experience, enhance workflow, and/or improve the work environment. Review of the facility's Quality Assurance (QA) Committee meeting documentation revealed meetings had been held on at least a monthly basis. Continued review revealed the QA Committee attendees included, but were not limited to the Administrator, the Medical Director, and the Director of Nursing (DON). Interview with the MDS Coordinator on 11/21/2022 at 2:50 PM, revealed he was part of the facility's QA team that met monthly regarding the facility's PI processes. He stated the QA Committee discussed the number of resident falls and the root cause of the falls. Further interview revealed the Administrator led the QA meetings and nursing notes were often reviewed. The MDS Coordinator further stated however, the facility had no system in place to audit or monitor the progress or effectiveness of the discussed interventions for fall prevention. Interview with the Medical Director on 12/08/2022 at 6:13 PM, revealed she was notified of falls which occurred in her own residents, and for other residents experiencing falls, she went over the details of those falls during the QAPI meetings. Per the Medical Director, the QAPI Committee discussed the root cause of falls and implemented strategies to prevent falls and reduce the impact of injury. Further interview revealed however, she felt the care had been provided for residents, but not documented as fully as needed to be. The Medical Director further stated she felt good about the overall care of residents after having issues identified during the survey investigation, and also felt there had been improved documentation, and communication in response to the new processes now implemented. Interview with the Director of Nursing (DON) on 11/17/2022 at 5:19 PM, revealed she attended the facility's monthly QAPI meetings and was an active participant of the QA Committee. Per interview, she was also involved in the facility's Clinical Morning Meetings which occurred Monday through Friday. The DON stated she conducted ongoing rounds in the facility to monitor for QA issues, and for regulatory compliance for all nursing practices and protocols. Continued interview revealed she worked closely with the Administrator for guidance and support related to clinical QA. According to the DON, the current falls of residents were discussed by the QA Committee; however, did not recall if any look back of all the falls was discussed. Further interview revealed the DON also did not recall if an audit of care plans was discussed to validate appropriate interventions had been implemented related to identifying the root cause of the fall. The DON further stated the QA Committee had not identified any concerns with the clinical systems in the facility. In addition, she stated she provided support for the facility's staff and ensured the safety and well-being of residents to promote quality of care. Interview with the Administrator on 11/21/2022 at 4:05 PM, revealed the facility's QAPI Committee met monthly, and discussed any clinical concerns brought to the QAPI Committee meetings. The Administrator revealed it was her responsibility to ensure all facility processes established by its Governing Body were maintained, including the facility's Quality Assessment and Assurance (QAA) and QAPI programs. Continued interview revealed the facility discussed the number of falls in the QAPI Committee meetings, and the DON and Medical Director were involved with that. She stated a Performance Improvement Plan (PIP) had been developed to decrease the number of resident falls within the facility, and the overall falls within the facility had decreased as a result. However, review of the facility's falls incident reports with the Administrator and SSA Surveyor revealed the number of falls within the facility increased over the last five (5) month review period. Further interview revealed the facility did not have a system in place to audit or monitor the effectiveness of the PIP implemented. Interview with the Regional Nurse Consultant (RNC) on 12/08/2022 at 7:13 PM, revealed the QAPI plan implemented should intervene and assist the facility in establishing relevant guidelines and policies for falls, fall assessments, care planning and implementation of action plans for falls. The RNC revealed the QAPI plan also assisted with root cause analysis, performance improvement plan and action plans. Continued interview revealed the facility's QAPI assisted with developing the goals and how to track response. Per interview, the RNC's duties included communication of the facility's QAPI actions to regional staff, and the Governing Body. According to the RNC, the facility's new QAPI process resulting from the outcome of the identified deficient practice was improved identification of issues during a weekly meeting which allowed for less time to pass between taking extra steps and being effective for residents's safety. Per the RNC, it was the Administrator's responsibility to watch, identify patterns, analyze, and implement changes based on the findings. He stated the IDT were to collaborate and figure out what the root cause of the falls was, and then decide what action plan to initiate. Further interview revealed the RNC served as part of the team to provide education/training for all staff regarding the care plan process, function, timing, how to retrieve, and ensured the audit information was taken to the facility's QAPI meeting every week and continued at the monthly QAPI meetings. ****The facility provided an acceptable Immediate Jeopardy Removal Plan on 12/05/2022, alleging removal of the Immediate Jeopardy on 11/30/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 11/28/2022, corrective action(s) were accomplished for those residents found to have been affected by the same deficient practice (Resident's #1, #2, #3, #7, and #8): (a) Resident #1 no longer resided at the facility; Resident #2 no longer resided at the facility; and Resident #3 no longer resided at the facility. (b) On 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse related to the resident's use of anti-coagulant therapy as related to falls. Resident #7's care plan was revised on 11/27/2022, by the RN Weekend Supervisor related to the resident's current one-on-one (1:1) supervision. (c) On 11/21/2022, the Charge Nurse revised and updated Resident #8's care plan to include appropriate interventions to prevent falls related to: the resident's continued refusal to wear a mobilizer boot on his/her right lower extremity; and refusing wear of non-skid slippers. Resident #8's care plan was updated to include a new mattress being placed on his/her bed as the resident stated he/she had slid off the mattress which caused his/her fall. In addition, Resident #8 had the non-compliant care plan updated on 11/21/22, by the MDS Coordinator. (d) On 11/28/2022, the facility implemented the MDS Coordinator continuing to monitor the falls care plans and update the care plans based on the resident's Fall Risk assessments completed on admission, re-admission, with a change of condition, a fall or quarterly. 2. On 11/28/2022, an audit was conducted of residents at risk for falls, and the facility identified and implemented corrective actions for residents residing in the facility and at risk for falls with the potential to be affected by the same deficient practice: a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. (b) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit of any residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. The audit included ensuring those falls were reviewed to ensure (as much as possible, considering the length of time since the fall), that they had been investigated and that a root cause had been defined for residents that had a fall in the last three (3) months. (c) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure appropriate assessments had been done post fall and that therapy screened the residents post fall. Additionally, the audit included ensuring the residents' care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure that Action Plans had been implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. (e) On 11/28/2022, the facility implemented a corrective action for residents who had a fall to ensure those residents were reviewed in the weekly Falls Meeting until the IDT decided that the residents' falls had been managed and they were no longer at HIGH RISK for falls. In addition, some residents might remain on the Falls Meeting list indefinitely for long-term monitoring purposes and based on their Falls Risk score. All falls were to be reviewed at the next daily, Monday through Friday (M-F) morning Clinical Quality Indicator (CQI) meeting following the fall to ensure that all post fall protocols were followed. (f) Beginning 11/28/2022, the facility implemented an additional corrective action for the DON/Unit Manager to monitor all falls post fall as well as, at the Falls Meetings weekly. In addition, the Nurse Consultant for the facility would be notified either in person or remotely of any fall sustained by any resident to offer guidance and input. 3. Beginning 11/23/2022, the facility additionally implemented corrective measures to promote systemic changes that ensure the deficient practice would not recur (a) On 11/28/2022, the facility implemented a systemic schedule that all falls would be reviewed at the next daily, M-F CQI meeting following the fall at this time, it would be determined if all post fall protocols were followed. Any concerns would be addressed. (b) Beginning 11/23/2022, the Administrator/DON/UM, with input from the RNC conducted an in-service training for all staff that reviewed: the Falls Policy; what to do if you (in your role) witness a resident who had fallen; Nurses: what to do when a resident fell ; why it was important to identify the root cause of a fall; what are FALL INTERVENTIONS; care plans/CNA's assignment sheets related to falls; action plans rolled out with a focus on falls; questions/answers. (c) Beginning 11/23/2022, the Administrator/DON/UM ensured staff knowledge was measured by a POST TEST performance that required 100% accuracy of the answers to pass. Any staff who failed to comply with the points of the in-service would be further educated and/or progressively disciplined as indicated. In addition, no staff would work prior to receiving the in-service after 11/28/22, this included any newly hired staff, agency staff, prn staff or any staff on any type of leave or vacation. 4. On 11/28/2022, the facility implemented a monitoring system of the corrective actions to ensure the deficient practice did not recur, (i.e., what Quality Assurance Program would be put into place and by what date the systemic changes for each deficiency would be completed). (a) Beginning 11/28/2022, the DON/Unit Manager were to review all falls at the next daily CQI meeting held M-F, to ensure that all post fall protocols were followed per policy and regulation. (b) On 11/28/2022, the daily CQI meeting was held and consisted of the Administrator, DON, UM, MDS, SSD, and Rehab Director and all residents who were at HIGH RISK for falls were to be discussed at the weekly Falls Meeting, until the IDT, decided that the residents' falls had been managed and the resident was no longer a HIGH RISK for falls. (c) On 11/28/2022, the results of the falls monitoring from the daily (M-F) CQI meetings as well as the weekly Falls Meetings were to be presented by the DON/Unit Manager at the weekly then monthly QAPI meetings. Any concerns or patterns were to be addressed and identified. (d) On 11/28/2022, if needed, an Action Plan/PIP was to be written by the QAPI Committee with input from the Regional Team. Any written Action Plan/PIP was to be monitored weekly by the Administrator until resolved. (e) On 11/28/2022, the facility also implemented a member of the Regional Team to attend the QAPI meetings either in person or remotely weekly, then monthly for three (3) months. The Regional Team members were to serve as a reference and additional oversight. The facility's QAPI Committee Members include: the Administrator, DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping/Laundry Supervisor, RVP/RDO/RNC/MDS Consultant (might attend if present), Pharmacy Consultant/Dietician (might attend if present), and the Medical Director/Nurse Practitioner. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 11/30/2022 1. (a) Review of the facility's documentation and medical record review revealed Resident #1, Resident #2, and Resident #3 no longer resided at the facility. (b) Review of the facility's documentation and care plans revealed on 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse to reflect the resident's use of ant-coagulation therapy as related to falls, and the care plan had been revised on 11/27/2022, by the RN Weekend Supervisor related to resident's current one-on-one (1:1) supervision. Continued review of Resident #7's care plan revealed resident centered goals for fall prevention and interventions in place as alleged. Observation of Resident #7 on 12/07/2022 at 9:13 AM and 12/08/2022 at 2:45 PM, revealed the resident in a room across from the nursing station, resting in a low bed with neon tape on the call light and 1:1 supervision, as care planned. Interview on 12/08/2022 at 4:09 PM, with the RN Weekend Supervisor revealed she had revised and updated Resident #7's care plan on 11/27/2022, related to 1:1 supervision. (c) Review of Resident #8's care plan revealed revisions were made to include appropriate interventions to prevent falls including the resident's refusal to: wear a mobilizer boot on his/her right lower extremity and non-skid slippers, and new mattress applied to his/her bed. In addition, review of Resident #8's care plan revealed a non-compliant care plan updated on 11/21/22, by the Charge Nurse and MDS Coordinator. Observation of Resident #8 on 12/07/2022 at 09:24 AM, revealed he/she was resting in a low bed with a new mattress in place, and wearing non-skid socks. (d) Review of the facility's documentation and interview with the Unit Manager (UM) on 12/08/2022 at 09:42 AM revealed she and the MDS Coordinator reviewed and updated the falls care plans based on the residents Fall Risk assessments completed upon admission, re-admission, quarterly, change of condition, or a fall. The DON was not available for interview. 2. (a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. Interview with UM for both units on 12/08/2022 at 9:42 AM revealed she and the DON and MDS conducted audits to ensure all residents had falls assessments completed in the last quarter, with any resident found to be high risk for falls receiving updates to their care plan. She further stated they also looked back 90 days to 08/22/2022 to determine that the residents who fell had correct interventions in place, consistent with the cause of the fall. The DON was not available to to interview due to illness and the MDS Coordinator was not available due to having surgery. (b) Review of the facility's documentation of residents at risk for falls and care plan audits dated 11/28/2022 through 12/06/2022, revealed the audits were completed as alleged of residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. Review of the facility documents additionally revealed those residents falls had been investigated and a root cause analysis had been identified with planned interventions implemented and monitored. Interview with the UM on 12/08/2022 at 09:42 AM revealed she and the MDS coordinator completed fall care plan audits including a lookback timeframe of three (3) months, from 08/22/2022. (c) Review of residents' Electronic Medical Record (EMR) review revealed assessments had been completed post fall and therapy had screened residents post fall. Continued review revealed the care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) Review of the facility's audit tools and documentation revealed the DON, UM, and MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview with the UM on 12/08/2022 at 09:42 AM revealed she, the DON and MDS Coordinator completed facility audits across the facility to ensure the action plans were implemented. (e) Interview with UM on 12/08/2022 at 9:42 AM revealed the QAPI team had been through every residents' record for fall risk and anticoagulant, and have added to care plans for bleeding risk and they process falls everyday. Further interview revealed residents who have had falls were reviewed during weekly falls meeting and continued until determined they were no longer high risk or if high risk continued, those residents would continue to be reviewed long term Interview with Administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview also revealed continued monitoring for residents with high risk for falls at weekly meeting. Review of the facility's CQI meeting sign in sheet and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meetings included discussion and review of residents' falls post fall as alleged, with the DON/Unit Manager as alleged. Interview on 12/08/2022 at 7:33 PM, with the Administrator revealed residents' care plans were revised immediately for antibiotic, skin concerns or any recent falls. The Administrator stated for the residents' comprehensive care plans, the facility utilized a tool's form, which included updated physician's orders. She further stated the managers for the unit would bring the tool to CQI to make sure the residents' care plans were revised or amended with actions discussed as needed. (f) Interview with administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview further revealed the DON and UM were monitoring falls on a weekly basis for four (4 ) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and this would be reviewed by regional staff. Interview on 12/08/2022 at 7:13 PM, the RNC revealed he had been providing direct oversight as alleged. 3. (a) Interview on 12/08/2022 at 9:42 AM, with the UM revealed beginning 11/28/2022, during the daily (M-F) CQI meeting, falls were the designated topic with daily discussion and review to determine if all post fall protocols were followed, and all concerns were addressed. (b) Review of the facility's, In-Service Falls Education Record revealed beginning 11/23/2022, the education had been provided as alleged for all staff regarding the Falls Policy; what to do if staff witnessed a resident who had fallen; for Nurses on what they should do when a resident fell ; why it was important for staff to identify the root cause of a fall; what the fall interventions were; review and update of care plans/CNA's assignment sheets related to falls; and action plans rolled out with a focus on falls. Further review revealed the Administrator, DON, and UM, with input from the RNC, conducted the in-service training for all staff. Interview on 12/08/2022 at 4:09 PM with RN #2; at 4:58 PM with LPN #1; at 4:35 PM with CNA #4, and at 6:42 PM with RN #3 and CNA #2 revealed they had been provided the education as alleged and had taken a test afterwards. (c) Review of the facility's post-tests information for the education provided for staff in all departments and the IDT team revealed all had taken the test and scored 100% as alleged. Interview on 12/08/2022 at 10:28 AM, with the HR Director revealed the education had been provided along with the POST TEST and requirement of 100% accuracy to pass the test. Continued interview revealed no staff worked prior to receiving the in-service after 11/28/2022, which included any newly hired staff, agency staff, prn (as needed) staff or any staff on any type of leave or vacation as alleged. Further interview revealed the education had been provided by the Administrator, DON, and UM with input and participation from the RNC. 4. (a) Review of the facility's CQI meeting sign in sheets and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meeting the DON/Unit Manager reviewed and discussed the post fall protocols being followed as per policy and regulation as alleged. Review of the facility's QAPI sign-in sheet and corresponding agenda dated 11/28/2022, revealed the meeting discussion included but not limited to the facility's system wide corrective actions implemented to ensure the deficient practice did not recur and date the systemic changes for each deficiency would be completed. Review of clinical records of sampled residents and training record review revealed the trainings were consistent with the removal plan. Review of QAPI documentation revealed membership, attendance, content and goals consistent with stated intent. Additional review revealed QAPI committee consisted of the Administrator, Director of Nursing (DON), Unit Manager (UM), Minimum Data Set (MDS), Business Office Manager (BOM), Social Service Director (SSD), Dietary Manager, Directors of Activities, Rehabilitation Director, Maintenance, Housekeeping/laundry supervisor, and the Medical Director/Nurse Practitioner. Further review of QAPI revealed committee developed audit tool to track education and monitoring. Interview with the Business Office Manager (BOM) on 12/08/2022 9:25 AM revealed QAPI works to resolve problems facility wide such as safety and falls. Additional interview revealed QAPI reviewed new tools for safety and fall prevention, and also discussed the two (2) falls for IJ at the last QAPI meeting. Interview with the UM on 12/08/2022 at 9:42 AM revealed the QAPI team has been through every resident record for fall risk and use of anticoagulant, and have added to care plans for bleeding risk. Interview revealed the last QAPI was this morning and they process falls everyday. (b) Review of the facility's CQI meeting sign in sheets and corresponding agendas revealed a CQI meeting was held on 11/28/2022, as alleged with the Administrator, DON, MDS, SSD, Unit Manager (UM), and Rehab Director. Continued review revealed it was determined all residents assessed as at HIGH RISK were to be discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the CQI information through 12/06/2022, revealed the members continued discussion of the same topics. Interview on 12/08/2022 at 11:23 AM with the SSD; and at 11:55 AM with the Rehab Director revealed they had participated in the daily CQI meeting, starting on 11/28/2022, discussion of audit reports of residents who were at HIGH RISK for falls which was discussed at the weekly Falls Meeting. Further interview revealed the review and discussion of HIGH RISK for falls residents continued in the weekly Falls Meeting until the IDT decided the residents' falls had been managed and the residents were no longer a HIGH RISK for falls. (c) Review of the facility's QAPI meeting sign in sheets and corresponding agendas revealed beginning on 11/28/2022, revealed the DON/Unit Manager (UM) presented the results of the falls monitoring from the daily (M-F) CQI meetings and Falls Meetings to the QAPI Committee. Continued review revealed it was determined all residents assessed as at HIGH RISK were discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the QAPI meeting information through 12/06/2022, revealed the DON/UM continued presenting and discussing of the same topics. Interview with the UM on 12/08/2022 Interview with the Administrator on 12/08/2022 at 7:33 PM revealed the DON and UM were monitoring falls on a weekly basis for four (4) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and would be reviewed by regional staff. (d) Review of the facility's audit tools revealed the DON/UM/MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview on 12/08/022 at 7:33 PM, with the Administrator revealed results of the falls audit/monitoring were being reviewed in the CQI meetings as well as the weekly Falls Meetings, and if an Action Plan/PIP was needed the QAPI Committee would write it with input from the Regional Team. The Administrator further stated she would participate in the development of any written Action Plan/PIP, and monitor it until it was determined to be resolved. (e) Interview on 12/08/022 at 7:33 PM, with the Administrator revealed the facility's QAPI Committee members included herself, the DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping and Laundry Supervisor. Continued interview revealed others who might attend if present in the facility at the time of the meeting were: the RVP, RDO, RNC, MDS Consultant, Pharmacy Consultant, Dietician, and Medical Director and/or Nurse Practitioner. Further interview revealed a member of the Regional Team had attended the QAPI Committee meetings either in person or remotely on a weekly basis. The Administrator further revealed the Regional Team's participation would decrease to every three (3) months, as determined by them, to provide additional oversight and serve as a reference for the facility. Interview on 12/08/2022 at 7:13 PM, with the Regional Nurse Consultant (RNC) revealed beginning 11/28/2022, he had been attending the facility's QAPI Committee meetings weekly either in person by remotely to provide direct oversight and act as a reference for the facility. Interview on 12/02/2022 at 6:18 PM, with the Medical Director revealed the facility held a QAPI meeting on 11/28/2022, and continued the meetings weekly. Per the Medical Director, she attended in person or remotely with the facility by phone for the QAPI Committee meetings. Continued interview revealed however, there were times when she was tied to activity at the hospital and could not attend the QAPI meetings. The Medical Director stated if she was unable to attend the meetings in person or remotely, she went over the actions discussed and taken by the QAPI Committee. Further interview revealed the facility's QAPI Committee would continue meeting weekly and move to monthly as determined by the need. In addition, the Medical Director stated during the QAPI Committee meetings there was discussion of falls [TRUNCATED]

Based on observation, interview, and a review of the facility policy, it was determined the facility failed to store serve and prepare food under sanitary conditions. A trash can was observed uncovered in the kitchen next to the hand sink, an egg carton was observed contaminated with egg shells and egg residue stored in the walk-in refrigerator, bags of bologna, packs of ground beef and ham was stored in the refrigerator not labeled and/or dated. Dented cans were stored available for use. Butter was observed stored uncovered and had food debris on it in the refrigerator. A steamer was observed with a build up of dirt and debris on the top surface. The findings include: A review of nutritional services policy titled Receiving Foods dated 03/25/2012, revealed all food items should be labeled with delivery date. According to the policy, cold food was to be stored under sanitary conditions. Potentially hazardous foods such as eggs should be stored below ready to eat items. Per the the policy, eggs should be stored clean and uncracked. Further review of the policy revealed all trash from the food service department would be disposed of in closed bags or receptacle with lids. Continued review of the policy and cleaning schedule revealed the steamer was required to be cleaned daily. Observation of the kitchen during the initial tour on 06/22/2021 at 9:12 AM, revealed a trash can with trash located next to the hand sink which was not covered with a lid. The top of the steamer had dirt and debris on the surface of the equipment. Butter was stored open and unlabeled in stand up refrigerator with food particles/debris on the surface of the butter. Ten (10) cracked egg shells were stored in the walk-in refrigerator in a carton with un-cracked eggs. Six zip-lock bags of bologna were stored on a refrigerator shelf not labeled or dated as to when open or repackaged. Two (2) dented cans of cranberry sauce, one (1) dented can of tomato sauce, and one (1) dented can pineapples was stored on a can food storage rack available for use. Two pack of hamburger meat and one pack of ham pieces was stored in the freezer not labeled or dated as to when stored/received. Kitchen observations on 06/23/2021 at 8:45 AM revealed the butter still stored in stand up refrigerator uncovered with food debris on the surface of the butter. The steamer was observed still soiled with dirt and debris on top surface of the equipment. Observation of the kitchen during the sanitization tour conducted on 06/24/2021 at 11:00 AM revealed butter still stored in stand up refrigerator uncovered with food debris on the surface of the butter. The steamer was observed still soiled with dirt and debris on top surface of the equipment. Interview with Dietary Aide #1 on 06/24/21 at 1:06 PM, revealed kitchen equipment was wiped down daily and the dietary aide hadn't noticed the dirt/debris on the steamer or that it was dirty. Interview with the Cook on 06/24/21 at 01:35 PM revealed when the cook finished for the day, the cook was supposed to wipe down equipment; however, the Cook stated she got busy and forgot to wipe the top of the steamer. Interview with the Dietary Manager (DM) on 06/24/2021 at 11:15 AM, revealed food should be labeled and dated in kitchen walk-in and freezer. The Garbage can was supposed to have a lid. However, the garbage can from the dining room was brought into the kitchen for trash to be disposed of and should have had a lid. The butter should have been covered and not cross contaminated with food debris. Dented cans should not be placed in rack for use and were required to be stored separately until credited from the food service company. The steamer should be cleaned daily. The Dietary Manager checked the kitchen weekly and was not aware of steamer being dirty. According to the DM, she had identified food labeling/dating issues in the past and stated she had retrained staff. The DM stated staff were supposed to label and date food when opened or received. The eggshells should have been discarded and not stored in the walk-in with un-cracked eggs. According to the Dietary Manager, trash that was not disposed of properly, food not stored correctly, labeled and dated, and soiled equipment could contaminate the residents food and had the potential to cause food borne illness.

Based on interview, record review and a review of the facility abuse policy, it was determined the facility failed to ensure an allegation of abuse for one (1) of three (3) sampled residents (Resident #1) was reported to the required state agencies. On 01/27/2021 at approximately 12:00 PM, Family Member #2 reported an allegation of abuse to the Administrator. The Administrator failed to report the allegation of abuse to the appropriate state agencies. The findings include: A review of the facility abuse policy titled Abuse, Neglect, and Exploitation undated, revealed in response to allegations of abuse, the facility must ensure that all alleged violations involving abuse or mistreatment were reported immediately to the Administrator but not later than two hours after the allegation is made if events involve abuse or within twenty-four hours if the events that cause the suspicion did not result in serious bodily injury. Further review of the policy also revealed the facility must ensure that all alleged violations involving abuse or mistreatment were reported to other state agencies in accordance with state law survey and certification agency through established procedures. An interview with Family Member (FM) #2, on 03/09/2021 at 12:57 PM, revealed FM #2 was outside Resident #1's room window on 01/26/2021 at 4:45 PM. The FM observed Licensed Practical Nurse (LPN) #2 and another unknown staff try to put Resident #1 back in bed. According to FM #2, the staff were rough with the resident and the resident hollered out in pain and was crying after staff put the resident back in the bed. Per FM #2, the Family Member contacted the facility Administrator the next day, on 01/27/2021 at approximately 11:00 AM, and informed the Administrator that LPN #2 was rough with Resident #1. The FM requested the incident be investigated. A review of the medical record for Resident #1 revealed the facility admitted the resident on 10/28/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired for cognition's with a Brief Interview for Mental Status (BIMS) score of 0 and was assessed to require the extensive assistance of two (2) staff for transfers. A review of a late entry nurse note dated 01/26/2021 at 6:19 PM revealed Licensed Practical Nurse (LPN) #2 noticed Resident #1 was on the side of the bed reaching for something and family was at the window. According to the note, Resident #1 was repositioned and stiffened and moaned during repositioning. An interview with the Director of Nursing (DON), on 03/09/2021 at 2:05 PM, revealed she and the Administrator talked to FM #2 on speaker phone on 01/27/2021 at approximately 11:00 AM. The DON stated FM #2 alleged that LPN #2 was rough with Resident #1 when assisting the resident to lay down the previous evening and caused the resident pain. According to the DON, she and the Administrator discussed the incident and did not think the incident was an allegation of abuse. The DON stated LPN #2's assignment was changed and the LPN was instructed to not provide care for Resident #1 at the request of FM #2. Interview with the Administrator on 03/10/2021 at 8:48 AM revealed the Administrator became aware of the allegation when she received a call from FM #2 on 01/27/2021 at approximately 11:00 AM. According to the Administrator, she discussed the incident with FM #2 but the family member did not allege that Resident #1 was abused by LPN #2 only that the resident hollered out when the staff were lying the resident down in bed. Further interview with the Administrator revealed she discussed the incident with LPN #2 but did not consider the incident an abuse allegation. The Administrator stated she did not report the allegation to the required agencies according to the policy.

Based on interview, record review, and a review of the facility policy on abuse, it was determined the facility failed to conduct an investigation of an abuse allegation for one of three sampled residents (Resident #1). On 01/27/2021, the Administrator received an allegation of abuse from a family member on Resident #1. However, the facility failed to conduct a thorough investigation of the incident and submit the results of the investigation to the required state agency within five working days. The findings include: A review of the facility policy on abuse titled Abuse, Neglect, and Exploitation undated, revealed that when reports of abuse occurred, an investigation is immediately warranted once the resident is cared for and initial reporting has occurred. The policy directed that staff document the entire investigation chronologically. Further review of the policy revealed the facility must have evidence that all alleged abuse allegations are thoroughly investigated and the results of the investigation reported to the state survey agency within five working days. A review of the medical record for Resident #1 revealed the facility admitted the resident on 10/28/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] reveled the resident was severely impaired for cognition's with a Brief Interview for Mental Status (BIMS) score of 0 and was assessed to require the extensive assistance of two (2) staff for transfers. A review of a late entry nurse note dated 01/26/2021 at 6:19 PM revealed Licensed Practical Nurse (LPN) #2 noticed Resident #1 was on the side of the bed reaching for something and family was at the window. According to the note Resident #1 was repositioned and stiffened and moaned during repositioning. An interview with Family Member (FM) #2, on 03/09/2021 at 12:57 PM, revealed FM #2 was outside Resident #1's room window on 01/26/2021 at 4:45 PM. The FM observed Licensed Practical Nurse (LPN) #2 and another unknown staff trying to put Resident #1 back in bed. The FM stated staff were rough with the resident and the resident hollered out in pain and was crying after staff put the resident back in the bed. Further interview with FM #2 revealed she contacted the facility Administrator the next day and reported to the Administrator that LPN #2 was rough with Resident #1 when the LPN was putting the resident back in bed. The FM stated she requested the incident be investigated. An interview with State Registered Nurse Aide (SRNA) #1, on 03/09/2021 at 9:18 AM, revealed the SRNA heard LPN #2 call for assistance on 01/26/2021 between 5:00 and 6:00 PM. The SRNA stated she went into Resident #1's room and the resident was on the side of the bed. Per the SRNA, the family was outside the window and when LPN #2 and SRNA #1 turned the resident around to lay the resident down on the bed. The SRNA stated the resident did holler out in pain and moaned. According to the SRNA, the resident does have pain and will holler out and moan when the resident is being moved or transferred. An interview with Licensed Practical Nurse (LPN) #2, on 03/09/2021 at 12:30 PM, revealed the LPN went to check on Resident #1 and noticed the resident sitting on the side of the bed with his/her feet hanging off the bed. The LPN stated the family was outside the window. According to the LPN #2, she called for assistance and she and SRNA #1 put the resident back in bed. The LPN stated the resident stiffened up and moaned when the resident was being positioned back into the bed. Further interview revealed LPN #2 returned to the nurse's station and was not aware of any concerns until the next day when she was informed by the Director of Nursing (DON) that the family had alleged she was rough with the resident when transferring the resident back to bed. The LPN stated the DON told her she was no longer to provide care for Resident #1. An interview with the Director of Nursing (DON), on 03/09/2021 at 2:05 PM, revealed she and the Administrator talked to FM #2 on speaker phone on 01/27/2021 at approximately 11:00 AM. The DON stated FM #2 alleged that LPN #2 was rough with Resident #1 when assisting the resident to lay down the previous evening and caused the resident pain. According to the DON, she and the Administrator discussed the incident and did not think the incident was an allegation of abuse. The DON stated LPN #2's assignment was changed and the LPN was instructed to not provide care for Resident #1 at the request of FM #2. Interview with the Administrator, on 03/10/2021 at 8:48 AM, revealed the Administrator became aware of the allegation when she received a call from FM #2 on 01/27/2021 at approximately 11:00 AM. According to the Administrator, she discussed the incident with FM #2 but the family member did not allege that Resident #1 was abused by LPN #2 only that the resident hollered out when the staff were lying the resident down in bed. Further interview with the Administrator revealed she did not complete an investigation of the allegation because she did not consider the allegation an allegation of abuse.

Based on observation, interview, policy review, and facility recipe review, it was determined the facility failed to ensure residents were served food that was palatable and at an appetizing temperature for ninety-three (93) residents who received meal trays during lunch on 09/15/19. Observations revealed the first cart arrived on the East Wing at 12:20 PM; however, a resident food tray remained on the cart at 12:55 PM (35 minutes later). A palatability test of the tray on 09/15/19 at 12:55 PM revealed the food on the tray was unpalatable. The findings include: Review of the facility's policy titled, Food Preparation, dated 03/25/12, revealed food would be served to residents that was palatable, attractive, and served at the appropriate temperature. Review of the facility's policy titled, Standardized Recipes, undated, revealed recipes would be followed in order to produce high quality, flavorful, and consistent products. A palatability and temperature test of a resident food tray conducted on 09/15/19 at 12:55 PM revealed the milk tasted warm and the temperature was 53.6 degrees Fahrenheit; the cauliflower tasted tepid, bland, and was 107 degrees Fahrenheit; and the pork loin was salty. A group interview conducted at 9:30 AM on 09/16/19 with six (6) facility residents revealed the food served at the facility was not seasoned. The residents further stated food was sometimes cold if they received their trays in their rooms. The residents also stated the pork loin served on 09/15/19 was too salty. Interview conducted with State Registered Nursing Assistant (SRNA) #1 on 09/15/19 at 1:08 PM revealed a resident food tray should not remain on the food cart for longer than thirty (30) minutes before it was returned to the kitchen to be replaced. The SRNA stated she was unsure why the trays sat so long on 09/15/19. Interview with the Cook on 09/18/19 at 2:00 PM revealed she was supposed to have added butter, salt, and parsley to the cauliflower; however, she could not remember if she had done so or not. The Cook stated she sometimes did not put salt in a dish because so many of the residents had blood pressure problems and she was afraid to add the salt even if the recipe called for it. The Cook also stated the pork loin was already seasoned with a marinade and she had not added any additional spices. Interview with the Dietary Manager (DM) on 09/18/19 at 2:15 PM revealed she did monitor tray pass and had not identified any concerns with meal trays not being served timely. The DM stated thirty-five (35) minutes was too long for a tray to sit on a tray cart before being sent back to the kitchen to be replaced. The DM stated the pork loin was in a marinade and that was what caused the extra salty taste. The DM stated the facility would not be serving pork loin prepared in that manner again. The DM stated the Cook should have followed the recipe as written. Interview conducted with the Director of Nursing (DON) on 09/18/19 at 6:56 PM revealed she completed audits to ensure meal trays were passed timely. The DON stated trays should be passed within thirty (30) minutes or sent back to the kitchen and replaced. The DON stated the facility does not have a specific policy related to the amount of time allowed for a meal tray to be passed and then sent back to the kitchen to be replaced. The DON stated she had not identified any concerns with meal tray pass, but stated thirty-five (35) minutes was too long for a meal tray to sit on the cart.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two (2) of twenty-two (22) sampled residents (Resident #101 and Resident #11). Resident #101 was discharged home; however, the facility inaccurately coded the resident on the MDS to be discharged to the hospital. In addition, the facility failed to code Resident #11's annual MDS assessment dated [DATE] to reflect the resident had a pressure ulcer present. The findings include: Interview with the Administrator on 09/18/19 at 11:50 AM, revealed the facility did not have a policy related to the accuracy of Minimum Data Set (MDS) assessments, but utilized the current Resident Assessment Instrument (RAI) Manual. 1. Review of the RAI 3.0 User's Manual revealed staff should code the assessment to accurately reflect the discharge status of a resident. Review of the medical record for Resident #101 revealed the facility admitted the resident on 09/05/19, with [DIAGNOSES REDACTED]. Review of Resident #101's discharge MDS assessment dated [DATE], revealed staff documented that the resident was discharged to the hospital. However, review of Resident #101's discharge summary dated 09/06/19 revealed the resident was discharged home on[DATE] against medical advice. Interview with the MDS Coordinator on 09/18/19 at 6:12 PM revealed he completed the discharge MDS assessment for Resident #101. He stated he made a mistake on the MDS and should have coded that the resident was discharged home. Interview conducted with the Director of Nursing (DON) on 09/18/19 at 7:04 PM revealed she did not monitor discharge MDS assessments, but was not aware of any concerns. 2. Review of Resident #11's medical record revealed the facility admitted the resident on 05/16/18 with [DIAGNOSES REDACTED]. Further review of Resident #11's medical record revealed staff identified during a routine weekly skin assessment on 02/19/19 that the resident had developed a Stage II pressure ulcer to the lateral side of the right foot. The record also revealed as of 09/20/19, the resident was continuing to receive treatment to the area. Review of physician orders [REDACTED].#11, both dated 02/20/19, revealed a treatment order was obtained to treat the area daily and as needed every shift. However, review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed the assessment was coded to reflect the resident did not have a pressure ulcer. Interview with the MDS Coordinator on 09/18/19 at 5:29 PM revealed Resident #11's MDS assessment dated [DATE] should have been coded to reflect the accurate status of the resident's skin condition, and stated, I just missed it. Interview with the Director of Nursing (DON) on 09/19/19 at 12:28 PM revealed the person that completes the MDS is responsible for ensuring the accuracy.

Based on observation, record review, and review of the facility's policies and procedures, it was determined the facility failed to review and revise the care plan for two (2) of twenty-two (22) sampled residents. The facility failed to review and revise the care plan of Resident #11 related to pressure sores and the care plan of Resident #74 related to fall interventions. The findings include: Review of the facility policy titled, Care Plan Process, revised 05/01/11, revealed each resident's plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. The policy also stated care plans would incorporate identified problem areas and be reviewed and revised periodically. Review of Resident #11's medical record revealed the facility admitted the resident on 05/16/18 with [DIAGNOSES REDACTED]. Further review of the resident's medical record revealed [REDACTED]. On 05/31/19, the pressure area was debrided and classified as a Stage III pressure ulcer. However, review of Resident #11's care plan revealed the plan had not been reviewed and revised after the debridement on 05/31/19 to reflect the wound being reclassified as a Stage III pressure area. Interview with the Wound Care Nurse on 09/19/19 at 12:45 PM revealed she was responsible for updating the care plan in relation to pressure ulcer wounds. The Wound Care Nurse stated she had updated a progress note for Resident #11, but failed to update the care plan. Interview with the MDS Coordinator on 09/18/19 at 5:29 PM revealed he was responsible for creating the Care Plan. However, the MDS Coordinator further revealed all staff were responsible for reviewing and revising the care plans. Interview with the Director of Nursing (DON) on 09/19/19 at 12:28 PM revealed the wound care nurse was responsible for revising a resident's care plan to reflect their wound status. The DON also stated she monitored accuracy of care plans by doing random audits, and had not identified any concerns with care plans not being reviewed or revised. 2. Review of Resident #74's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #74's medical record revealed the resident sustained [REDACTED]. Review of Resident #74's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5) indicating the resident had severe cognitive impairment. Review of Resident #74's Care Plan revealed the resident was at risk for falls, and interventions were implemented to prevent falls for the resident. However, the care plan had not been revised with the intervention of ensuring the resident wore tennis shoes and not boots. Interviews on 09/19/19, at 10:20 AM with State Registered Nursing Assistant (SRNA) #6, and at 10:24 AM with SRNA #8 revealed they utilized the care plan to know what the resident care needs were. However, neither SRNA was aware that Resident #74 was not to wear boots, in an effort to prevent further falls. Interview with the Director of Nursing (DON) on 09/19/19 at 11:47 AM revealed the intervention implemented after the resident's fall on 07/26/19, was to ensure the resident did not wear boots, but the intervention had not been added to the resident's care plan, and therefore, the staff caring for the resident would not be aware of the intervention.

Based on interview, record review, and facility policy review it was determined the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for four (4) of seven (7) sampled residents (Residents #3, #4, #5, and #6). Staff and resident interviews revealed the facility required staff members to remove incontinence briefs on all incontinent residents during the night. Interviews with Residents #3, #4, #5, and #6 revealed the facility had not discussed this issue with them prior to implementing incontinence briefs being removed at night. The residents stated this caused feelings of humiliation and embarrassment, and they felt demeaned. The findings include: Review of the facility's policy titled Resident Rights, date unknown, revealed a resident was to be treated with consideration, respect, and full recognition of his/her dignity and individuality. 1. Record review revealed the facility admitted Resident #3 on 04/01/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/30/15, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 15, which indicated the resident was cognitively intact and interviewable. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of bowel and bladder. Review of the Care Directive (Certified Nursing Assistant Care Plan) revealed the resident was always incontinent of bowel and bladder. The Care Plan directed staff to check and change the resident every two (2) hours and as needed. Review of the July 2015 physician's orders [REDACTED]. Review of the Comprehensive Care Plan with an onset date of 04/09/15, revealed the resident was experiencing incontinence episodes of bowel and/or bladder and directed staff to check and change the resident every two (2) hours and as needed, as well as to use adult brief for dignity. Review of the Weekly Skin Integrity Data Collection dated 05/04/15 through 06/29/15 revealed the resident's skin was intact and dry. Interview with Resident #3 on 06/29/15 at 10:00 AM revealed the resident was not provided incontinence briefs during the night multiple times throughout the last month. The resident stated facility staff had indicated the reason for not providing him/her incontinence briefs during the night was related to staff using too many diapers. During interview with the resident, he/she stated, I have MS. The disease is bad enough. I don't need to lose any more dignity. Going without the briefs is humiliating and demeaning. Further interview with the resident on 06/29/15 at 1:50 PM revealed facility staff had not asked the resident or discussed the decision to discontinue incontinence briefs at night with the resident until staff members were directed to not use them. Interview with Resident #3 on 06/30/15 at 12:33 PM, revealed facility staff told the resident they were not providing briefs during the night so he/she could air out. The resident stated the terminology air out was offensive, ridiculous, and embarrassing to him/her. Further interview revealed the resident had been having frequent loose stools and although he/she realized they did not smell good, the fact that the facility wanted staff to air him/her out was embarrassing. 2. Record review revealed the facility readmitted Resident #4 on 02/19/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment revealed the facility assessed the resident's BIMS score to be 11, indicating the resident was interviewable. Further review of the MDS revealed the resident required extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of urine and occasionally incontinent of bowel. Review of the Care Directive revealed the resident was occasionally incontinent of bowel and bladder. Interventions included for staff to check and change the resident every two (2) hours and as needed. Review of the June 2015 physician's orders [REDACTED]. Review of the resident's Comprehensive Care Plan with a review date of 05/18/15, revealed the resident was experiencing incontinence episodes of bowel and/or bladder. The staff was directed to check and change the resident every two (2) hours and as needed, and to use adult brief for dignity. Review of the Weekly Skin Integrity Data Collection dated 05/01/15 through 06/26/15 revealed the resident's skin was intact and dry. Interview with Resident #4 on 06/29/15 at 4:15 PM revealed facility staff had informed him/her that his/her incontinence brief was to be left off during the night so he/she could get air. During the interview, the resident became very tearful and began crying. Further interview revealed that not using incontinence briefs during the night made him/her feel bad. The resident stated, I don't feel comfortable without my night clothes on. I've always wore my underclothes at night. He/she later stated, It's embarrassing that they leave them (the brief) off. Resident #4 stated that a family member had purchased pull-ups to keep in his/her nightstand because the facility would not provide him/her briefs to wear at night. The resident stated he/she had asked facility staff to leave his/her incontinence briefs on during the night; however, the staff continued to remove his/her briefs at night against his/her wishes. 3. Record review for Resident #5 revealed the facility admitted the resident on 01/09/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 01/07/15, revealed the facility assessed the resident's BIMS score to be 11, indicating the resident was interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of urine and always continent of bowel. Review of the Care Directive revealed the resident was always incontinent of bowel and occasionally incontinent of bladder and directed staff to check and change the resident every two (2) hours and as needed; the resident may wear adult briefs. Review of the June 2015 physician's orders [REDACTED]. Review of the resident's Comprehensive Care Plan, review date of 04/15/15, revealed the resident was experiencing incontinence episodes of bowel and/or bladder and directed staff to check and change the resident every two (2) hours and as needed; and to use adult brief for dignity as needed. Review of the Weekly Skin Integrity Data Collection dated 04/28/15 through 05/26/15 revealed the resident's skin was intact and dry, and indicated there was some redness. Further review of the weekly skin assessments dated 06/02/15 through 06/16/15 revealed the resident's skin was intact and dry. Interview with Resident #5 on 06/29/15 at 6:30 PM, revealed facility staff told the resident they did not have incontinence briefs to provide during the night on a couple of occasions. The resident stated not being able to use the incontinence briefs made him/her feel bad about myself. 4. Record review revealed the facility readmitted Resident #6 on 05/04/15 with [DIAGNOSES REDACTED]. Review of the Admission MDS revealed the facility assessed the resident's BIMS score to be 12, indicating the resident was interviewable. Further review of the MDS revealed the resident required extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of bowel and bladder. Review of the Care Directive revealed the resident was always incontinent of bowel and occasionally incontinent of bladder; and staff was directed to check and change the resident every two (2) hours and as needed. Review of the June 2015 physician's orders [REDACTED]. Review of the resident's Comprehensive Care Plan with an onset date of 05/12/15, revealed the resident was experiencing incontinence episodes of bowel and bladder. Interventions included for staff to check and change the resident every two (2) hours and as needed, and to use adult brief for dignity as needed. Review of the Weekly Skin Integrity Data Collection dated 05/04/15 through 05/25/15 revealed the facility assessed the resident to have redness on his/her buttocks. Interview with Resident #6 on 06/30/15 at 3:50 PM revealed the resident required assistance to the bedside commode and wore incontinence briefs. Further interview revealed facility staff told the resident they had ran out of incontinence briefs. The resident stated the incident occurred the week before and he/she had asked a family member to bring pull-ups from home for him/her to use at night. Further interview revealed facility staff used chucks (incontinence pads) instead of using the briefs that he/she preferred. The resident stated, No one saw anything, but it still made me feel uncomfortable. Review of a facility Staff Memo addressed to all night shift staff members revealed, All residents are to be chucked!! No briefs. The memo further stated if a resident had a brief on in the bed, staff would be written up. If the staff members had questions, they were to contact the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The memo was signed by Unit Manager (UM) #1. Interview with UM #1 on 06/29/15 at 2:51 PM revealed facility staff was instructed to remove the incontinence briefs on all incontinent residents on a nightly basis. Further interview revealed she was aware that Resident #3 was upset about not being provided the incontinence briefs at night. The UM stated Resident #3 had loose stools and needed to be aired out to prevent skin problems. Interview with Certified Nurse Assistant (CNA) #6 on 06/29/15 at 5:15 PM revealed incontinence briefs were removed at night unless the resident demanded to keep them on and the family and facility were agreeable with the decision. The CNA stated this had been facility practice for the last couple of months. The CNA stated she was instructed to leave incontinence briefs off at night because of the budget. Further interview with the CNA revealed she was aware that there had been quite a few residents that were really upset about the change in practice. Interview with CNA #7 on 06/29/15 at 5:25 PM revealed the facility's Administrative Staff had indicated the incontinence briefs were costing a lot of money and it would be better to let residents air out at night. Interview with CNA #8 on 06/29/15 at 5:33 PM revealed the change in practice to not provide briefs at night was related to cutting back on expenses. Interview with CNA #9 on 06/30/15 at 11:48 AM revealed she had been instructed to not use incontinence briefs on residents during the night due to a shortage of briefs. The CNA stated that if a resident requested an incontinence brief she provided them with one. Interview with CNA #10 on 06/30/15 at 12:52 PM revealed she had also been instructed to leave the incontinence briefs off residents during the night. The CNA stated, I left the briefs off the first day, then I started thinking about their dignity and started putting them on. Further interview with CNA #10 revealed she had attended a facility verbal in-service meeting in May 2015, during which staff members were instructed to let residents air out and that the facility was over budget on briefs. Interview with CNA #11 on 06/30/15 at 2:49 PM revealed she had attended the verbal in-service regarding not using incontinence briefs during the night. The CNA stated the change in practice was initially explained as a budget concern and was later indicated as a way of letting residents air out. Further interview revealed the CNA was working the night the new practice was put into effect. The CNA stated she was caring for Residents #3 and #5 that night, and both residents were very upset and requested incontinence briefs. The CNA stated she informed UM #1 the following morning of Residents #3 and #5's concerns. Further interview with CNA #11 revealed the residents were not given an explanation related to the change in facility practice prior to implementing the change. Interview with Registered Nurse (RN) #2 on 06/30/15 at 2:32 PM revealed night shift staff members had been instructed to leave the incontinence briefs off residents to prevent skin breakdown. Interview with the ADON on 06/30/15 at 5:37 PM revealed she had been instructed that facility staff was not to use incontinence briefs during the night shift. The ADON stated she had not been informed of the reason behind the change. She stated Resident #4 had been crying and upset the day before (06/29/15) related to staff members removing his/her incontinence brief at night after the resident had requested to wear a brief. The ADON stated she had instructed the night shift staff members to allow Resident #4 to wear briefs at night. Further interview revealed the ADON had not identified any concerns with dignity. Interview with UM #1 on 06/30/15 at 6:12 PM revealed staff members were first instructed via note to not use incontinence briefs on any residents during the night. Further interview revealed the facility allowed the residents to use incontinence briefs at night upon request. The UM stated she was not aware of any residents being embarrassed about not having incontinence briefs at night and she was also not aware that residents' family members were purchasing briefs for resident use. Interview with the DON on 06/30/15 at 6:29 PM revealed facility staff had initially been instructed to not use incontinence briefs during the night shift to let residents air out to prevent skin issues. The DON stated the change in practice was not related to budget concerns. She stated she was not aware of residents having concerns regarding not being supplied incontinence briefs at night. The DON stated if a resident requested a brief, then staff should be giving them one. She further stated the facility had not changed or created a new policy prior to initiating the change in practice or discussed it with residents and/or families. The DON stated the Administrator had instructed her to initiate the change in practice regarding incontinence briefs at night. She stated she was unsure what the rationale was for the change in practice. Further interview revealed the facility did not individually assess the residents for the need for incontinence briefs at night. The DON stated she had not identified any concerns with not using incontinence briefs during the night. Interview with the Administrator on 06/30/15 at 7:06 PM revealed the facility was letting some of the residents air out to prevent skin breakdown. Further interview revealed the Administrator stated it was her understanding that residents that were susceptible to skin breakdown were not to have their incontinence briefs during the night shift unless they were heavy wetters or had diarrhea. Further interview revealed the Administrator was unaware if assessments had been completed prior to the change in practice. She stated she did not make the decision to remove the briefs at night and that the decision was absolutely not done because of budget cuts. The Administrator stated she was not aware of any resident being upset regarding the change and she had not identified any concerns with dignity.

Based on interview, record review, and facility policy review it was determined the facility failed to follow and implement interventions in the plans of care for four (4) of six (6) sampled residents (Residents #3, #4, #5, and #6). Review of the comprehensive care plans for Residents #3, #4, #5, and #6 revealed interventions to provide incontinence briefs for the residents to maintain dignity. Staff and resident interviews revealed the facility failed to provide incontinence care briefs for residents at night resulting in feelings of embarrassment, humiliation, and feeling demeaned. The findings include: Review of the facility's policy entitled Resident Care Plan, with a revision date of December 2008, revealed a resident's care plan was a brief written portrait of the resident and an individualized guide of the nursing care needed. Further review of the policy revealed the care plan should reflect the resident's current needs, problems, goals, care, treatment, and services. Review of the facility's policy, Resident Rights, date unknown, revealed a resident was to be treated with consideration, respect, and full recognition of his/her dignity and individuality. 1. Record review for Resident #3 revealed the facility admitted the resident on 04/01/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/30/15, revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact and was interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of bowel and bladder. Review of the Care Directive (Certified Nurse Assistant Care Plan) revealed the resident was always incontinent of bowel and bladder. Interventions included for staff to check and change the resident every two (2) hours and as needed. Review of the July 2015 physician's orders [REDACTED]. Review of the resident's Comprehensive Care Plan with an onset date of 04/09/15, revealed the resident was experiencing incontinence episodes of bowel and/or bladder. Interventions included for staff to check and change the resident every two (2) hours as needed, and to use adult brief for dignity. Interview with Resident #3 on 06/29/15 at 10:00 AM revealed the facility failed to provide the resident with incontinence briefs during the night resulting in him/her having feelings of humiliation. Resident #3 stated, I have MS. The disease is bad enough. I don't need to lose any more dignity. Going without the briefs is humiliating and demeaning. Further interview with Resident #3 on 06/29/15 at 1:50 PM revealed facility staff had not asked or discussed with him/her the decision to discontinue the use of briefs at night prior to implementing the change. 2. Record review for Resident #4 revealed the facility readmitted the resident on 02/19/15, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment revealed the facility assessed the resident's BIMS score to be 11, indicating the resident was interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of urine and occasionally incontinent of bowel. Review of the facility Care Directive revealed the resident was occasionally incontinent of bowel and bladder, and directed staff to check and change the resident every two (2) hours and as needed. Review of the June 2015 physician's orders [REDACTED]. Review of the Comprehensive Care Plan reviewed on 05/18/15, revealed the resident was experiencing incontinence episodes of bowel and/or bladder and the plan directed staff to check and change the resident every two (2) hours and as needed; and to use adult brief for dignity. Interview with Resident #4 on 06/29/15 at 4:15 PM revealed facility staff removed his/her incontinence brief during the night. The resident stated he/she wanted to wear the brief, but facility staff told him/her that he/she could not wear a brief at night. Resident #4 stated he/she was embarrassed and it made him/her feel bad. The resident became upset, tearful, and began to cry during the interview. 3. Record review for Resident #5 revealed the facility admitted the resident on 01/09/15, with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 01/07/15, revealed the facility assessed the resident's BIMS score to be 11, indicating the resident was interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of urine and always continent of bowel. Review of the Care Directive revealed the resident was always incontinent of bowel and occasionally incontinent of bladder, and directed staff to check and change the resident every two (2) hours and as needed. Further review revealed the resident may wear adult briefs. Review of the June 2015 physician's orders [REDACTED]. Review of the resident's Comprehensive Care Plan with a review date of 04/15/15, revealed the resident was experiencing incontinence episodes of bowel and/or bladder. The staff was directed to check and change the resident every two (2) hours and as needed, and to use adult brief for dignity as needed. Interview with Resident #5 on 06/29/15 at 6:30 PM revealed facility staff had failed to provide the resident with incontinence briefs during the night, which resulted in the resident feeling bad about himself/herself. 4. Record review for Resident #6 revealed the facility readmitted the resident on 05/04/15, with [DIAGNOSES REDACTED]. Review of the Admission MDS revealed the facility assessed the resident's BIMS score to be 12, indicating the resident was interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assistance with bed mobility and toileting. The facility also assessed the resident to be frequently incontinent of bowel and bladder. Review of the Care Directive revealed the resident was always incontinent of bowel and occasionally incontinent of bladder; staff was to check and change the resident every two (2) hours and as needed. Review of the June 2015 physician's orders [REDACTED]. Review of the Comprehensive Care Plan with an onset date of 05/12/15, revealed the resident was experiencing incontinence episodes of bowel and bladder, and directed staff to check and change the resident every two (2) hours and as needed; and to use adult brief for dignity as needed. Interview with Resident #6 on 06/30/15 at 3:50 PM revealed the facility failed to provide the resident with incontinence briefs during the night resulting in him/her having feelings of being uncomfortable. Review of a facility Staff Memo addressed to all night shift staff members revealed, All residents are to be chucked!! No briefs. If a resident has a brief on in the bed you will be written up. If the staff members had questions, they were directed to contact the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The memo was signed by Unit Manager (UM) #1. Interview with UM #1 on 06/29/15 at 2:51 PM revealed incontinence briefs were removed during the night from all incontinent residents facilitywide. UM #1 stated the practice was intended to allow residents to air out to prevent possible skin problems. Further interview on 06/30/15 at 6:12 PM revealed staff was responsible to follow resident care plans. Interviews with Certified Nurse Assistants (CNAs) #9, #10, and #11 on 06/30/15 at 11:48 AM, 12:52 PM, and 2:49 PM, respectively, revealed they were responsible to review and follow each resident's CNA care plan every shift. Further interview revealed the resident's incontinence care needs would be indicated on the CNA care plan. The CNAs stated they were instructed to remove the resident's incontinence briefs during the night shift for all residents. Interview with Registered Nurses (RNs) #2 and #3 on 06/30/15 at 2:32 PM and 3:09 PM, respectively, revealed they were responsible to review and follow the resident's comprehensive care plan each shift. The RNs stated interventions regarding incontinence care were located on the comprehensive care plan; however, they had been instructed to remove incontinence briefs during night shift hours to prevent skin breakdown. Interview with the Assistant Director of Nursing (ADON) on 06/30/15 at 5:47 PM, revealed the comprehensive care plan stated to use incontinence briefs for dignity and facility staff should follow the care plan; however, facility staff was instructed by the Director of Nursing (DON) and Administrator to remove the residents' briefs at night. Interview with the Director of Nursing (DON) and the Administrator on 06/30/15 at 6:29 PM and 7:06 PM, respectively, revealed facility staff had been directed to no longer use incontinence care briefs on residents at night unless they were requested by the resident. The Administrator and DON stated they did not consider dignity issues or resident care plans prior to making the decision to discontinue all briefs during the night shift. Further interview revealed interventions for incontinence care were located on the care plan and facility staff was responsible to follow the care plan.