Every finding on record at Medical Management Health and Rehab Center

Based on observations, staff interviews, and a review of the facility's policy titled Food Storage Guideline, the facility failed to discard expired food items and failed to properly label, and date food products as required. The facility also failed to maintain sanitary practices during the handling of dishware and utensils, resulting in wet nesting and cross contamination risks. These deficient practices had the potential to place 69 residents who received an oral diet from the kitchen at risk for contracting a foodborne illness.Findings Include:A review of the facility's policy titled Food Storage Guideline dated 03/2024 documented that non perishable food was required to have a delivery date and once opened, an open date. Items were to be discarded by the expiration or use by date listed on the product. The policy stated that prepared foods received upon delivery, such as cheese, salads, and luncheon meats, were required to have a delivery date and once opened, an open date and discard date. Food prepared in the facility was required to have a prepared date and a discard date.During the initial tour on 04/17/2026 at 7:43 AM with the Administrator, the kitchen inspection revealed food stored in the dry storage area designated for emergency preparedness. The dry storage area contained five 46 ounce nectar consistency items with an expiration date of 01/27/2026. One open 10 count package of hamburger buns was observed without proper storage, labeling, or dating. The reach in freezer contained one two gallon bag of pre packaged food that lacked required labels and dates. The Administrator verified that the beef patties inside the bag were prepared on 04/15/2026, but no expiration or discard date had been provided. The walk in refrigerator contained one one gallon bag holding a cut onion dated 04/14/2026, but no expiration or discard date was documented. Additionally, a two gallon bag containing pre packaged ham was observed, and the Administrator confirmed that the expiration date appeared to be either 04/06/2026 or 04/16/2026, but the date was difficult to read due to blurriness caused by moisture.An observation and interview on 04/18/2026 at 1:00 PM with Dietary Aide (DA) II revealed that dirty dishes were transported to the dishwashing area through a square opening in the wall. As dishes moved from the washing machine to the drying area, wet nesting was observed on plates and serving domes. DA II operated a low temperature dish machine and demonstrated unsanitary hand hygiene practices by using the same gloves to retrieve dirty dishes and to handle, prepare, and store clean dishes. DA II explained that he retrieved dirty dishes from the window, scraped food from the plates, sprayed them on a rack, ran them through the dishwasher, removed them, and stacked them to dry, repeating this process until all dishes were completed. He confirmed that he did not have a drying rack or any method to allow dishes to air dry properly and that he had never changed his gloves or washed his hands between handling clean and soiled dishware and utensils. The Dietary Manager confirmed the observation and instructed DA II to rewash the dishes and change gloves.An interview on 04/18/2026 at 1:11 PM with the Dietary Manager confirmed that all dietary staff had been in serviced on labeling and dating requirements as well as the dishwasher procedure. The Dietary Manager stated that DA II was in a hurry and had limited workspace. She acknowledged that food items in the walk in refrigerator and reach in freezer had preparation dates but lacked required use by dates. She also stated that moisture on the ham packaging caused the date to blur and that she planned to implement a new labeling process. The Dietary Manager further stated that the Registered Dietitian had indicated the thickener stored in the dry storage area was still acceptable to keep, explaining that the use by date referred to freshness; however, she confirmed that the product was not to be used past that date.

Based on observation, staff interviews, record review, and facility policies Resident Rights and Smoking Policy-Residents the facility failed to protect and promote the rights of one of 11 resident (R) (R28) related to smoking. The facility census 71.A review of the facility's policy titled Resident Rights (revised 02/2021) documented under Policy Interpretation and Implementation stated that residents were to be free from corporal punishment or involuntary seclusion, and from physical or chemical restraints not required to treat the resident's symptoms. It further stated that residents had the right to exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.A review of the facility's policy titled Smoking Policy - Residents (dated 2001) documented under Policy Interpretation and Implementation stated that any smoking related privileges, restrictions, and concerns (e.g., need for close monitoring) were to be noted on the care plan, and all personnel caring for the resident were to be alerted to these issues. Under Progressive Disciplinary Action, the policy stated that due to the danger posed by violations, a progressive disciplinary format would be strictly enforced: first offense - verbal warning; second offense - suspension of privileges for 24 hours; third offense - termination of smoking privileges.A review of the clinical record for R28 revealed that the resident was admitted on [DATE] with diagnoses including, but not limited to: Schizophrenia, Anxiety Disorder, Nicotine Dependence (Cigarettes) With Unspecified Nicotine Induced Disorders, Major Depressive Disorder, Antisocial Personality Disorder, Unsteadiness on Feet, Other Abnormalities of Gait and Mobility, and Need for Assistance With Personal Care.The resident's most recent Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively alert and oriented. Section E (Behavior) documented behaviors not exhibited. Section GG (Functional Abilities) documented no impairment in upper extremity range of motion and impairment on both sides in lower extremity range of motion. Under Mobility Devices, wheelchair was documented. Under Self Care, supervision or touching assistance was documented for eating.A review of the Care Plan for R28, initiated 06/18/2025, documented the Focus: I have had an actual fall related to poor balance. The Goal (target date 06/11/2026) stated the resident would resume usual activities without further incident. Interventions included referral to therapy for evaluation and possible reacher. A revised Focus dated 04/18/2026 documented Tobacco Usage: Resident is a smoker. Residents deemed it unsafe to smoke. Interventions included the resident require supervision while smoking.Smoking observations on 04/18/2026 and 04/19/2026 at 9:30 AM revealed that R28 was not present.A review of a witness fall report dated 04/03/2026 documented under Immediate Action Taken: MD notified, reevaluation of smoking completed, reeducation on fall prevention provided, and resident would no longer be a smoker but would be allowed chewing tobacco.A Progress Note dated 02/10/2026 by LPN JJ documented a witnessed fall: Nurse was informed by staff that resident was being pushed up ramp and resident was leaning over in wheelchair holding smoke box and fell coming into doorway. staff verbalized and reeducated resident on proper body positioning.On 04/18/2026 at 10:00 AM, during the Resident Council meeting, R28 stated three times that his smoking privilege had been taken away and expressed a desire to smoke again. The Activities Director was present.An interview on 04/19/2026 at 9:10 AM with the Director of Nursing (DON) revealed that residents displaying unsafe behaviors-such as not sitting upright or experiencing falls-would have their smoking privileges revoked. The DON confirmed that R28 was assessed upon admission and was to be evaluated every three months. The DON stated that R28 was admitted with an unsteady gait and was often observed bent over throughout the day. The DON further stated that following the fall on 04/03/2026, R28 was deemed unsafe to smoke, and his smoking rights were revoked without prior discussion in the IDT team, and disciplinary action was documented per policy. The DON reported that interventions included verbal prompts to maintain an upright position and a referral to therapy.An interview on 04/19/2026 at 10:09 AM with the Administrator revealed that she had not discussed R28's smoking privileges with her team in any meetings. She stated she expected a smoking assessment to be completed and any violations addressed. The Administrator noted that R28 used a wheelchair throughout the day, particularly during meals, and staff ensured he was seated closer to the table. She stated that his smoking rights should not have been revoked, and that he should instead have been positioned nearer to the ashtray.An interview on 04/19/2026 at 10:19 AM with the Staff Scheduler/Certified Medication Assistant (HH) revealed she was present during the fall on 04/03/2026. She stated that R28 was attempting to reach the ashtray and was seated at the end/corner of the table.An interview on 04/19/2026 at 10:35 AM with Licensed Practical Nurse (LPN) JJ revealed that she performed a smoking evaluation after being informed that R28 had fallen while attempting to stand and reach for the ashtray located in the center of the adjacent table. LPN JJ stated she assessed R28 on 04/03/2026 following the fall and determined that he was not safe to smoke.

Based on record review, staff interviews, and the facility policy titled Resident Assessment - Coordination with PASARR Program, the facility failed to conduct a Preadmission Screening and Resident Review (PASARR) Level II assessment for one of 24 sampled residents (R28). This deficient practice had the potential to affect residents who required Level II PASARR specialized services.Findings include:A review of the facility policy dated 12/19/2022 titled Resident Assessment-Coordination with PASARR Program revealed:Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority.Record review revealed R28 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Bipolar disorder, Anxiety disorder, Schizophrenia, Psychotic disorder (other than schizophrenia), and Depression (other than bipolar). Medications listed included but were not limited to: Ativan 1 mg three times a day, Haloperidol 10 mg two times a day, Depakote 500 mg two times a day, and Olanzapine 20 mg at bedtime.Review of the PASRR Level I application Resident Identification Screening Instrument revealed R28 had Schizophrenia and another mental disorder; however, no date was documented.Review of R28's Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section A (Identification Information) that the Preadmission Screening and Resident Review (PASARR) Level II assessment was not selected. Review of Section C (Cognitive Patterns) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Section I (Active Diagnoses) documented diagnoses including, but not limited to, anxiety disorder, depression, bipolar disorder, and psychotic disorder.Review of R28's Care Plan Report revealed a Focus indicating R28 was at risk for adverse effects of antipsychotic medication. R28 used antipsychotic medications related to behavior management, disease process, schizophrenia, dementia, and major depressive disorder.Review of R28's clinical record revealed no PASRR Level II.Interview on 04/18/2026 at 9:37 AM with the Social Services Director (SSD) revealed the SSD stated that on R28's initial application he had a diagnosis of Alzheimer's. She stated he also had diagnoses of another mental disorder and schizophrenia. The SSD stated she realized this past Wednesday that R28 did not have a Level II PASRR. She stated she spoke with the Administrator and the Business Office Manager (BOM), and they were in agreement that he should have a Level II. She stated she had not submitted for a Level II yet because she needed the Medical Director to complete another DMA 6. She stated the MD was available by phone, and she planned to try to reach him on Monday. The SSD stated she was responsible for PASRRs and acknowledged it was an oversight on her part.Interview on 04/18/2026 at 9:51 AM with the Business Office Manager (BOM) revealed the BOM stated the SSD told her on Wednesday that R28's diagnoses on his DMA 6 might trigger a Level II PASRR. The BOM stated the SSD told her she would resubmit. The BOM stated she had not seen R28 or noticed any behaviors because her office was located in the front of the building.Interview on 04/18/2026 at 9:55 AM with the Administrator revealed that R28 should have Level II PASARR. She stated they had their mock survey on Wednesday, and it was discovered at that time that he did not have Level II. She stated they were cited on PASRRs a couple of years ago. The Administrator stated she did not have an excuse for R28 not having a PASRR Level II.

Based on observations and staff interviews, the facility failed to ensure the confidentiality of resident medical records for one of 71 sampled resident (R) (R 67).Findings include:Observation on 04/18/2026 at 10:57 AM, Licensed Practical Nurse (LPN) AA locked the medication cart and walked away from the medication cart leaving the computer screen open and with the R67's medication list and information exposed. LPN AA entered R67's room and placed the glucometer on R67 bedside table without a barrier. LPN AA dropped the test strip on the floor and left the room to retrieve another test strip. LPN AA returned to the medication cart, unlocked the cart and retrieved a test strip. LPN AA again walked away from the med cart then turned around and looked at the computer screen and closed the screen.Interview on 04/18/2026 at 11:15 AM with LPN AA revealed that she should have locked the computer screen before she walked away from the med cart. She stated that when she came back to the cart it was too late.Interview on 04/19/2026 at 2:30 pm with Registered Nurse (RN) KK revealed that her expectation is for nurses to lock or cover the computer screen when they walk away from the medication cart.

Based on observations and interviews, the facility failed to provide effective infection control practices related to fingerstick blood sugar checks for one of 24 sampled resident(R) (R67).During medication administration on 04/19/2026 at 10:57 AM, Licensed Practical Nurse (LPN) AA removed the glucometer from the medication cart, sanitized her hands, cleaned the glucometer, and placed it in her gloved hand. LPN AA entered R 67 room and placed the glucometer directly on the resident's bedside table without a barrier. LPN AA wiped R67's right index finger with an alcohol pad and performed the blood glucose fingerstick. After completing the procedure, LPN AA cleaned the glucometer with a disinfectant wipe and placed the wet glucometer directly on top of the medication cart to dry without a barrier.An interview conducted on 04/18/2026 at 11:15 AM with LPN AA revealed she had no explanation for why she did not place a barrier between the resident's bedside table and the glucometer.An interview conducted on 04/19/2026 at 2:30 PM with Registered Nurse (RN) KK revealed that her expectation was for nurses to use a barrier between the glucometer and the resident's bedside table during blood glucose testing.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature level for five residents (Resident (R) 67, R53, R47, R14, and R22 who resided on one of four halls (B hall). The water temperatures on the facility's B hall ranged between 138.9 degrees Fahrenheit (F) and 149.1 degrees F on 6/16/2025. On 6/16/2025, the Maintenance Supervisor failed to notify the Administrator, nursing staff, and residents and implement interventions to protect the residents on the B hall when the water temperatures became excessively hot after they were adjusted and checked around noon on 6/16/2025. The facility's failure to ensure the environment was free of accident hazards by not maintaining safe water temperatures placed residents at continued risk of serious injury, harm, or impairment. Immediate Jeopardy (IJ) at 483.25(d) - Accidents, at a Scope and Severity of a J, was identified on 6/16/2025 and was determined to exist on 6/16/2025 when hot water temperatures in excess of 138 degrees F were first noted on B hall. The Administrator and Corporate Administrator were notified of the Immediate Jeopardy on 6/17/2025 at 12:25 PM. An acceptable Immediate Jeopardy Plan of Removal was provided on 6/17/2025 at 9:59 PM and included adjusting the water heater on B hall to a safe setting, monitoring temperatures through 6/17/2025, assessing residents for burn injuries, and staff education on water temperature safety. The survey team validated implementation of the removal plan, and the Immediate Jeopardy was removed on 6/18/2025 at 7:15 PM. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a E, no actual harm with potential for more than minimal harm isolated. Scope and severity for a pattern of potential harm. Findings include: Review of the facility's policy titled, Safety of Water Temperatures, revised 12/2009, revealed, . Tap water in the facility shall be kept within a temperature range to prevent scalding of residents . Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees F . or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log . Review of the facility's document titled, Temperature Monitoring, dated 5/21/2025 and provided by the facility, revealed there were no water temperatures recorded on 6/16/2025. During an interview on 6/16/2025 at 1:54 PM, R67 stated he did not have cold water, and the hot water was so hot his fingers were almost scalded when he washed his hands. During observations and interviews on 6/16/2025, the Maintenance Supervisor took the temperatures and verified the temperatures of the following residents' water: a. 2:57 PM - R67's water temperature was 118 degrees F in the sink at 2:57 PM with no cold water. Review of R67's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE] with diagnoses including dementia and paranoid schizophrenia. Review of R67's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 5/8/2025 and located in the EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. The MDS revealed the resident had no impairment with range of motion (ROM) and mobility. R67 could and did use the sink independently. b. 3:02 PM - R47's water temperature was 149.1 degrees F in the sink. Review of R47's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included cellulitis, venous insufficiency, and lymphedema. Review of R47's quarterly MDS, with an ARD of 4/22/2025 and located in the EMR under the MDS tab, revealed R47 had a BIMS score of 12 out of 15, which indicated she was moderately cognitively impaired. The MDS recorded that the resident had no upper extremity impairment and used a walker with substantial to maximal assistance. R47 could and did use the sink independently. c. 3:03 PM - R53's water temperature was 147.0 degrees F in the sink and 148.8 degrees F in the shower. Review of R53's undated admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and type II diabetes mellitus (DM). Review of R53's quarterly MDS, with an ARD of 3/11/2025 and located in the EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident was unable to complete the interview. The facility assessed the resident to be severely cognitively impaired for daily decision making with long term and short-term memory problems. The MDS revealed the resident had no upper extremity impairment and used a manual wheelchair with partial to moderate assistance. R53 could and did use the sink independently. d. 3:05 PM - R22's water temperature was 138.9 degrees F in the sink at 3:05 PM. Review of R22's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including type II DM and schizophrenia. Review of R22's quarterly MDS, with an ARD of 5/13/2025 and located in the EMR under the MDS tab, revealed R22 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS recorded the resident was able to ambulate to the bathroom independently. R22 could and did use the sink independently. e. 3:06 PM - R14's water temperature was 148.1 degrees F in the sink at 3:06 PM. Review of R14's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of type 2 DM. Review of R14's quarterly MDS, with an ARD of 3/25/2025 and located in the EMR under the MDS tab, revealed R14 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS recorded that the resident had no upper or lower extremity impairment, did not use any mobility devices, and could walk 150 feet with supervision or touching assistance. R14 could and did use the sink independently. During an interview on 6/16/2025 at 3:29 PM, the Maintenance Supervisor revealed it rained over the weekend, and the pilot light went out under the building so he relit it today at 8:00 AM so the water would not be cold. The Maintenance Supervisor stated he tested the water temperatures at 8:00 AM and he had to increase the water temperature because the water temperatures were still too cold, but he did not record the temperatures. The Maintenance Supervisor indicated that he retested the temperatures of the B hall rooms at noon, and the water was excessively hot, but he did not record them, and he turned the water heater down. The Maintenance Supervisor stated that he did not notify staff about the excessively hot water temperatures when he identified them at noon, nor did he put any interventions in place to prevent all the residents on the B hall from injuries. During an interview on 6/16/2025 at 4:46 PM, the Administrator stated she should have been notified as soon as the Maintenance Supervisor identified water temperatures were too high so that the problem could be corrected and to prevent accidents from happening to the residents. During an interview on 6/20/2025 at 12:13 PM, Licensed Practical Nurse (LPN) 4 stated she was notified by a coworker on the morning of 6/16/2025 that the Maintenance Supervisor had adjusted the water temperature on the B hall so the residents would have warm water. LPN4 stated she was not told when the water got too hot for the residents to use later in the day. Each hall has a designated water heater. Temperatures were checked on all halls in the facility with no other concerns identified.

Based on interview, record review, and facility policy review, the facility failed to have ongoing communication and collaboration with the dialysis center for one of two residents (Resident (R) 38) reviewed for dialysis out of a total sample of 22. This had the potential for R38's care needs to not be met. Findings include: Review of the facility's policy titled, End Stage Renal Disease, Care of the Resident with dated 10/2010, revealed, . Agreements between this facility and the contracted ESRD [End Stage Renal Dialysis] facility include all aspects of how he resident's care will be managed including . How information will be exchanged between the facilities . Review of the Nursing Facility Dialysis Contract, dated 10/24/2017, revealed, . Emergency and non-emergency changes in a resident's medical condition will be immediately communicated by the party having primary knowledge of the change to the other party. Center will communicate with Nursing Facility [sic] via the Dialysis Communication Form, including when a resident refuses scheduled medical management or non-compliance with medical management relating to dialysis treatment (i.e., diet, fluid restriction and medications). Center will also provide Nursing Facility with a Patient Plan and Progress Report for each resident served . Review of R38's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R38 was readmitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of R38's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an assessment reference date (ARD) of 3/18/2025, indicated R38 was coded as receiving dialysis during the seven day look back period. Review of R38's Care Plan, dated 7/17/2024 and located under the Care Plan tab in the EMR, indicated a Focus of . The resident needs hemodialysis r/t [related to] renal failure . The interventions were Check and change dressing daily at access site. Document [sic]. Do not draw blood or take BP [blood pressure] with graft. Encourage me to go for the scheduled dialysis appointment. I receive dialysis 3 times per week [sic] . Review of R38's Physician Orders, dated 12/2/2024 and located under the Orders tab in the EMR, indicated an order for dialysis on Tuesday, Thursday, and Saturday. Review of R38's Dialysis Communication Form, provided by the facility and dated for the months of 4/2025, 5/2025, and 6/2025, indicated incomplete information documented by the facility pre and post dialysis and the dialysis center during this time. Incomplete information included medications administered prior to dialysis, pre and post weights, medications administered during dialysis, any changes in condition, start and end times of dialysis, shunt location/status, bruit/thrill present, bleeding present, general condition of resident once back at the facility, vital signs and date and time of assessments, and nurses' signatures. During an interview on 6/19/2025 at 10:50 AM, Licensed Practical Nurse (LPN) 5 stated, All the blanks on the form either by us [facility] or by the dialysis enter should be documented in. If the dialysis center does not fill in their section, we [facility] are to call the center or fax the sheet back to the dialysis center. LPN5 confirmed there was incomplete documentation for the months of 4/2025 through 6/2025 on the dialysis communication forms for R38. During an interview on 6/20/2025 at 11:00 AM, the Assistant Director of Nursing (ADON) confirmed all the blanks, either by the facility or the dialysis center, should be filled in completely. The ADON stated, This sharing of information between the facility and the dialysis center is essential for the complete care of this resident.

Based on observation, interview, record review, and document review, the facility failed to follow current standards of practice for flushing a PICC (Peripherally Inserted Central Catheter) line for one of one resident (Resident (R)73) observed with a PICC line during the medication administration observation out of a total sample of 22. This failure had the potential to cause R73 to not receive the whole dose of an intravenous antibiotic and increased the risk of occlusion of the catheter. Findings include: Review of the Lippincott Nursing Center's article titled, Topics in Progressive Care: Peripherally inserted central catheters: What you should know , located at https://www.nursingcenter.com, revealed, . Adequate flushing is essential to prevent catheter occlusion. All catheters require flushing with normal saline before medication administration to clear the lumen and assess catheter function, between each medication administered to prevent drug precipitate, and after medication administration to again clear the line . Review of the website at https://patientslearn.uams.edu/wp-content/uploads/sites/95/2018/04/PICC-Care-Sub-Q_Securement_Device.pdf indicated the following procedure to be used for PICC line using the SASH [Saline Antibiotic Saline Heparin] method, . Open alcohol pad, pick up lumen, remove . cap and scrub the connector with alcohol for 15 seconds and let dry for 15 secs. Attach the saline syringe, open clamp and flush your line with 10 ml of saline. Close clamp and remove syringe. Scrub end of the catheter line with alcohol for 15 seconds and allow to dry for 15 secs [seconds]. Take the cap off of the tubing and attach tubing to your line . Review of R73's undated Face Sheet, located under the 'Profile tab in the EMR, indicated R73 was admitted to the facility on [DATE] with the diagnosis of sepsis. Review of R73's Physician's Orders, dated 5/28/2025 and located under the Orders tab in the EMR, indicated R73 had an order for Daptomycin (an antibiotic) Intravenous Solution Use 500 mg (milligrams) intravenously every 48 hours for sepsis until 6/30/2025. There were no orders for flushing the PICC line. During a medication administration observation on 6/19/2025 at 4:55 PM, Registered Nurse (RN) 1 did not flush R7's PICC line prior to connecting the IV tubing. Once connected, it was observed the IV would not run to infuse the antibiotic. RN1 attempted to squeeze the chamber to obtain more IV solution, but this did not make the IV start to run. RN1 then attempted to prime the IV tubing, but this did not make the IV solution begin to run properly. After 10 minutes of the nurse attempting various techniques to get the IV solution to run, RN1 was asked if flushing the PICC line prior to connecting the IV tubing would make it run. RN1 stated, Yes, I forgot to do that. RN1 flushed the PICC line with 10 ml (milliliters) of saline and reconnected the IV tubing and the IV solution when turned on, began to infuse the antibiotic. During an interview on 6/20/2025 at 1:15 PM, the Assistant Director of Nursing (ADON) stated, I expect the nurses to use the SASH method when administering an IV antibiotic through a PICC line. The ADON was asked if R73 had orders for the SASH method to be used when administering the IV antibiotic. The ADON stated, No, he doesn't. I would expect the nurses to have called the doctor to ask for this order.

Based on interview, record review, and facility policy review, the facility failed to provide education on the risks and benefits of psychotropic medications prior to the initiation of such medication to one of five residents (Resident (R)38) reviewed for unnecessary medication out of a total sample of 22. This had the potential to cause R38 not to be able to give informed consent for the use of a psychotropic medication. Findings include: Review of the facility's policy titled, Use of Psychotropic Medication(s), dated 4/01/2025 revealed, . Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics . Prior to initiating or increasing a psychotropic medication the resident, family, and/or resident representative must be informed of the benefits, risk, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase . Review of R38's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R38 was readmitted to the facility on [DATE] with the diagnosis of dependence on renal dialysis. Review of R38's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an assessment reference date (ARD) of 3/18/2025, revealed R38 was coded for receiving dialysis and an antianxiety medication while a resident in the facility during the seven day look back period. R38 was coded as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R38 was cognitively intact. Review of R38's Physician's Orders, dated 8/27/2024 and located under the Orders tab in the EMR, revealed an order for Ativan [an antianxiety medication] Oral Tablet 0.5 MG [milligram] (Lorazepam) Give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday [sic] for Anxiety [sic] Give prior to dialysis [sic] . Review of R38's EMR in its entirety revealed no documented evidence that the risks and benefits of Ativan usage were explained to R38 prior to the initiation of Ativan. During an interview on 6/20/2025 at 11:50 AM, R38 was asked if the staff had informed her of the risks and benefits of Ativan prior to the start of the medication. R38 stated, I don't remember if they did or not. During an interview on 6/20/2025 at 12:48 PM, the Assistant Director of Nursing (ADON) was asked if R38 had been informed of the risks and benefits of Ativan prior to the start of the medication. The ADON stated she would have to go and investigate this and get back to the surveyor. At 1:40 PM, the ADON returned and stated, There is no documentation in the resident's record that indicates the resident was provided with the risks and benefits of Ativan use. This is supposed to be done prior to the start of any psychotropic medication.

Based on observation, interview, record review, and document review, the facility failed to ensure one of six residents (Resident (R) 7) observed during the medication administration observation, was free from a significant medication error. The medication error occurred when the licensed nurse failed to recognize the physician ordered insulin was not expired and could have been administered to R7. This failure had the potential for R7 to experience hyperglycemia and if left untreated could have led to diabetic ketoacidosis. Findings included: Review of R7's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R7 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus. Review of R7's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an assessment reference date (ARD) of [DATE], indicated R7 was coded as receiving insulin on seven of seven days during the look back period. Review of R7's Care Plan, dated [DATE] and located under the Care Plan tab in the EMR, indicated R7 had a focus of The resident has Diabetes Mellitus [sic] and at risk for episodes of hyperglycemia and hypoglycemia. Interventions were Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . Ensure I have sliding scale coverage for hyperglycemic episodes. Monitor/document/report PRN [as needed] any s/s [signs/symptoms] of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd [abdominal] pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma [sic] . Review of R7's Physician Orders, dated [DATE] and located under the Orders tab in the EMR, indicated R7 had an order for Novolin R Insulin Inject as per sliding scale: if 0-149 = 0 units; 150 - 200 = 6 units; 201 - 300 = 10 units; 301 - 400 = 12 units; 401 - 1000 = 15 units subcutaneously three times a day. R7 also had an order, dated [DATE], for Novolin R insulin inject five units subcutaneously three times a day. Review of R7's Medication Administration Record (MAR), located under the Orders tab in the EMR and dated 6/2025, indicated R7 was to receive Novolin R insulin five units and Novolin R per sliding scale was to be administered at 11:30 AM daily. During an observation on [DATE] at 11:14 AM, Licensed Practical Nurse (LPN) 3 performed a fingerstick and obtained a blood sugar reading of 533 for R7. LPN3 was preparing to draw up the Novolin R insulin and noted the expiration date on the insulin vial was [DATE]. LPN3 stated, I would rather be safe than sorry about giving this, I can't give this insulin because it is expired. At 11:22 AM, LPN3 called the pharmacy and notified them the insulin was expired and the facility did not have any more Novolin R. The pharmacy notified LPN3 that they would send the driver out at 12 noon to deliver the insulin to the facility. During an observation on [DATE] at 11:30 AM, LPN3 notified the Medical Doctor that R7's blood sugar was 533. The physician gave orders to LPN3 to add Novolin N 20 units subcutaneously to be administered along with Novolin R insulin. LPN3 did not notify the medical doctor that the ordered Novolin R insulin was not available at this time for administration to R7. During an observation on [DATE] at 12:30 PM, the Assistant Director of Nursing (ADON) came to the nurses' station and notified LPN3 that the Medical Doctor had new insulin orders for R7. Review of R7's Physician Orders indicated an order dated [DATE] at 12:39 PM for Humulin R 5 units subcutaneously and Humulin R Insulin inject as per sliding scale: 0 - 149 = 0; 150 -200 = 6 units; 201 - 300 = 10 units; 301 - 400 = 12 units; 401 - 1000 = 15 units and Call MD one time only. At 12:46 PM, LPN3 administered Humulin R 20 units subcutaneously to R7. This was one hour and 15 minutes past R7's scheduled insulin administration time. During an interview on [DATE] at 2:34 PM, LPN3 was asked if she notified the physician that there was no Novolin R insulin available to administer to R7 when she spoke with him at 11:30 AM. She stated, I probably should have but I didn't. LPN3 was asked if she had checked the emergency kit in the medication refrigerator to see what insulin was available to give to R7. LPN3 replied, I knew it was coming from the pharmacy, and I could wait and give the insulin because I had an hour to give it. LPN3 was asked if she had performed an assessment on R7 while waiting on the insulin to arrive at the facility. She stated, No. LPN3 was asked how long the facility had to implement physician ordered interventions that are given in response to critical lab results. She stated, I think it should be immediately. During an interview on [DATE] at 2:51 PM, the ADON stated, The nurse should have recognized the insulin was not expired until after midnight tonight. I expect the nurses to recognize when insulin is expired and to have notified the doctor when the nurse called to let him know that we did not have the Novolin R in the facility and ask if he wanted something else instead to be given to the resident for a blood sugar of 533. The nurse is expected to look in the emergency kit to see what insulin is available so the doctor will know. The nurse, once a blood sugar is noted to be high, should contact the doctor immediately and get the intervention to the resident and not wait for a long period of time. The ADON was asked if she performed an assessment of R7 while LPN3 was waiting on the insulin to arrive from the pharmacy. She stated, No, I didn't. The ADON confirmed an assessment should have been done. Review of the facility's policy Administering Medications dated [DATE] indicated Medications shall be administered in a safe and timely manner, and as prescribed .

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the Pharmacist Consultant identified and reported to the facility and to the prescriber that a PRN (as needed) antianxiety medication did not have a duration of use for one of seven residents (Resident (R) 1) reviewed for unnecessary medications out of a total sample of 22. This failure placed the resident at risk for not being reevaluated for the medication necessity. Findings include: Review of the facility's policy titled, Consultant Pharmacist, revised October 2022, revealed, A qualified Consultant Pharmacist is to be retained for the purpose of coordinating, supervising, and reviewing the facility's pharmacy services . The Consultant Pharmacist is expected to be conversant with all State and Federal laws and codes related to pharmacy services. The Consultant Pharmacist will be responsible for the following activities . Review the drug regimen of each resident at least monthly and report any irregularities to the Attending Physician or Medical Director, Director of Nursing, and the Administrator. Physicians who are new to the facility should be notified of this procedure by the nursing staff . Review of the facility's policy titled, Use of Psychotropic Medication(s), dated 4/01/2025, revealed, . Policy Explanation and Compliance Guidelines . A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories . anti-anxiety . Psychotropic medications . PRN orders for psychotropic medications . shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber for the rational for the extended time period and indicate a specific duration . Review of R1's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included intracranial injury, dementia, anxiety disorder, bipolar disorder, and generalized idiopathic epilepsy. Review of R1's Clinical Physician Orders, located in the resident's EMR under the Orders tab, revealed an order dated 8/31/2021 and revised on 2/7/2025 for Lorazepam [a fast-acting antianxiety medication used to treat seizures] 2ML [milliliters] (4MG) . Inject 1ML intramuscularly every 1 hours as needed for seizure related to other seizures . The End date [duration] was indefinite. Review of R1's Monthly Medication Reviews (MMRs) for the prior six months, completed by the facility's Pharmacy Consultant (PC), revealed no documented evidence the pharmacist identified the PRN psychotropic mediation lacked a duration/stop date. During an interview and record review on 6/19/2025 at 12:49 PM, the ADON confirmed R1 had an active order for lorazepam with no stop date. The Assistant Director of Nursing (ADON) confirmed there were no pharmacy recommendations to the resident's physician that identified the need for a stop date. During an interview on 6/20/2025 at 11:34 AM, the PC stated he normally does not touch (recommend) PRN psychotropic medications which included R1's fast acting analytic medication of lorazepam because it was used for seizures. The PC stated it was his understanding that a duration or stop date was only needed for a psychotropic medication if it was used for behaviors. During an interview on 6/20/2025 at 12:25 PM, the Administrator stated it was her expectation during R1's MMR, the PC would have identified that the lorazepam ordered did not have a stop date.

Based on staff interviews, record review, and a review of the facility's policy titled Care Plans - Comprehensive, the facility failed to develop and implement comprehensive care plans that addressed sexual abuse incidents, prevention measures, and safety interventions. This deficient practice affected three of three residents (R) (R1, R2, R3) reviewed for abuse. Findings include: The facility policy titled, Care Plans - Comprehensive revised October 2010 documented Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The Revisions portion of the policy further documented 8. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. R#1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness; altered mental status; unspecified dementia with behavioral disturbance, vascular dementia, severe with agitation and psychotic disorder with delusions due to known physiological condition. According to the 9/20/2024 Quarterly Minimum Data Set (MDS), the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of zero out of 15. Review of R1's care plan revealed: 1. No updates addressed the inappropriate sexual behaviors directed at R2 and R3. 2. No interventions for increased supervision needs. 3. No behavioral management strategies. 4. No room placement considerations. R 2 was admitted on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance; dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and pain, unspecified. According to the 10/1/2024 Annual MDS, the resident had severe cognitive impairment with BIMS score of 99 due to the inability to complete the interview. Review of R2's care plan revealed: 1. No modifications were made after the 5/13/2024 incident. 2. No interventions that addressed safety related to room placement. 3. No psychological support measures. 4. No enhanced monitoring requirements. R3 was admitted on [DATE] with diagnoses including neurocognitive disorder with lewy bodies; other extrapyramidal and movement disorders; Alzheimer's disease with early onset, and psychotic disorder with delusions due to known physiological condition. According to the 5/23/2024 Significant Change in Condition MDS, the resident had severe cognitive impairment with BIMS score of 99 due to inability to complete the interview. A review of R3's medical record revealed a care plan dated 7/12/2022 which documented the resident was considered bedfast all or most of the time related to preference of condition (Hospice) status. Additionally, the care plan dated 5/1/2024 documented that R3 was at risk for increased anxiety and restlessness from having individuals come into her room and being unable to speak loud enough to alert others of concerns. Review of R3's care plan revealed: 1. No updates following the alleged sexual abuse incidents of 4/11/2024 and 5/13/2024. 2. No interventions that addressed increased vulnerability to abuse. 3. No modifications to address the psychological impact related to the incidents. 4. No enhanced monitoring measures despite the documented risk of anxiety and inability to call for help. During an interview on 10/29/2024 at 12:00 p.m., Certified Nurse Assistant (CNA) BB stated she discovered R1 undressed in bed with R2, while R3's brief was pulled down. During an interview on 10/29/2024 at 1:48 p.m., Social Worker CC stated her duty included helping modify care plans to enhance safety and monitor resident adjustment over time. Social Worker CC stated she was not made aware of the situation (referring to the inappropriate sexual behavior directed at Residents R2 and R3) and, therefore, could not update care plans appropriately. Social Worker CC stated she moved R1 on 5/1/2024 to the room opposite R3's room due to roommate conflicts but would not have made the switch had she known about the sexual abuse incidents involving R1 and R3. During an interview on 10/29/2024 at 3:16 p.m., Charge Nurse DD stated she did not complete an assessment on R2 or R3, which prevented appropriate care plan updates based on assessment findings. During an interview on 10/30/2024 at 9:10 a.m., the Administrator stated the facility's protocols were not followed, including the requirement to update care plans following incidents of abuse. The Administrator acknowledged that failures to update the care plans left residents without proper protective interventions. During an interview on 10/30/2024 at 9:45 a.m., the Director of Nursing stated that a facility-wide assessment of all vulnerable residents should have been completed, with care plan updates to reflect assessment findings and necessary interventions. During an interview on 10/30/2024 at 10:30 a.m., the Medical Director stated that coordination with psychiatry services was limited because the facility did not inform him of the full scope of what occurred with the residents at the time. The Medical Director emphasized that the course of action after any potential abuse should include updating care plans to address room placement and prevent contact between the involved residents. The Medical Director stated that the facility's decision to move R1 to a room directly opposite R2 and R3's room lacked reasonable judgment and should have been addressed in the process of updating care plans. Cross reference F600

Based on record review, family and staff interviews, and a review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to report allegations of sexual abuse to the State Survey Agency within the required timeframes and failed to notify the residents' Responsible Parties of the incidents. This deficient practice affected two of three residents (R) (R2 and R3), who were reviewed for abuse reporting. Findings include: The facility's Abuse, Neglect and Exploitation policy reviewed on 4/4/2024 documented under the Reporting and Response Portion of the policy . The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, State Agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: (a) Immediately, but not later than two (2) hours after allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or (b) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R #1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included traumatic subdural hemorrhage without loss of consciousness; altered mental status; unspecified dementia with behavioral disturbance, vascular dementia, severe with agitation and psychotic disorder with delusions due to known physiological condition. According to the 9/20/2024 Quarterly Minimum Data Set (MDS), the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of zero out of 15. R #2 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance; dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and pain, unspecified. According to the 10/1/2024 Annual MDS, the resident had severe cognitive impairment with BIMS score of 99 due to inability to complete the interview. R #3 was admitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies; other extrapyramidal and movement disorders; Alzheimer's disease with early onset, and psychotic disorder with delusions due to known physiological condition. According to the 5/23/2024 Significant Change in Condition MDS, the resident had severe cognitive impairment with BIMS Score of 99 due to inability to complete the interview. A review of the facility's incident reports revealed: 1. The facility failed to report the 4/11/2024 incident involving R#1 and R#3 to the State Survey Agency until 5/21/2024 (41 days after the incident occurred). During an interview on 10/29/2024 at 10:00 a.m., R3's family member, listed as the Power of Attorney, stated they were never called nor made aware of any alleged sexual abuse that involved the resident. During an interview on 10/29/2024 at 10:11 a.m., R2's listed responsible party/guardian denied being made aware of any alleged sexual abuse involving the resident. During an interview on 10/29/2024 at 12:00 p.m., Certified Nurse Assistant (CNA) BB stated they reported their observations immediately to the charge nurse on duty when they discovered R1 undressed in bed with R2. During an interview on 10/29/2024 at 1:48 p.m., Social Worker CC stated her duty as a Social Worker serving nursing home residents who have allegedly experienced sexual abuse was to focus first on ensuring immediate safety and mandatory reporting to authorities. Social Worker CC stated she was not notified of either incident when it occurred, which affected her ability to intervene adequately. During an interview on 10/29/2024 at 3:16 p.m., Charge Nurse DD stated she was told of the incident; however, she did not observe the residents firsthand. Charge Nurse DD stated she had completed an incident report and contacted the relevant family members and the resident's attending physician. When advised of the residents' family member's denial of being notified of the incidents, Charge Nurse DD stated she had to cover their oversight. During an interview on 10/30/2024 at 9:10 a.m., the Administrator stated the facility's protocols were not followed. The Administrator revealed that for the first inappropriate sexual contact made by R#1 towards R#3 on 4/11/2024 at 8:30 p.m., Charge Nurse DD did not notify the Director of Nursing, the Assistant Director of Nursing, or the Administrator until the following day. During an interview on 10/30/2024 at 9:45 a.m., the Director of Nursing stated the facility's expectation was immediate notification of administration, physician, and responsible parties following any allegation of abuse. The DON added that law enforcement should have been notified if sexual abuse was suspected. During an interview on 10/30/2024 at 10:30 a.m., the Medical Director stated they were not notified of the incidents until the next day after they had happened and were not available to examine the residents personally. The Medical Director emphasized that delayed notification impacted their ability to evaluate the residents and direct appropriate medical interventions properly. (Cross reference F600)

Based on observation, staff interviews, record review, and a review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to protect two residents' (R) (R2, R3) right to be free from sexual abuse by a resident (R1). Specifically, the facility failed to implement appropriate interventions and separate vulnerable residents from potential perpetrators. Findings include: The facility's Abuse, Neglect and Exploitation policy reviewed on 4/4/2024 documented, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation or resident property. R1 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness; altered mental status; unspecified dementia, unspecified severity with other behavioral disturbance, vascular dementia, severe with agitation and psychotic disorder with delusions due to known physiological condition. Review of the 9/20/2024 Quarterly Minimum Data Set (MDS), the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of zero out of 15. R2 was admitted on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance; dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and pain, unspecified. Review of the 10/1/2024 Annual MDS, the resident had severe cognitive impairment with BIMS score of 99, which represented an inability to complete the interview. R3 was admitted on [DATE] with diagnoses including neurocognitive disorder, other extrapyramidal and movement disorders, Alzheimer's disease with early onset, and psychotic disorder with delusions due to a known physiological condition. Review of the 5/23/2024 Significant Change in Condition MDS, the resident had severe cognitive impairment with BIMS score of 99, which indicated an inability to complete the interview. A review of the facility's Resident Incident Report dated 5/21/2024 documented that on 4/11/2024 at approximately 8:30 p.m., Certified Nurse Assistant (CNA) HH found R1 behind the closed door in R3's room. According to the report, R1 pulled down R3's brief, and his brief was pulled down as well. While the report documented the facility implemented 15-minute checks for 72 hours with R1, they failed to protect R3 and other residents from further abuse. A review of the facility's census revealed that during the 4/11/2024 incident, R1 lived in room D12-1 while R3 shared room B4-2 with R2. During visual observation, these rooms were separated by an L shaped hallway with a nurse station facing the D hallway and a large dining room acting as a barrier between R1 and R2, and R3's room. However, after the first incident, the facility moved R1 to Room B92. The room was directly across from Room B4 (the room occupied by R2 and R3) and was out of the line of sight from all nursing stations, and no monitoring mechanisms were in place. The facility's Resident Incident Report, dated 5/14/2024, documented a second incident involving all three residents. According to the report, CNA BB reportedly found R1 in bed with R2, while R3's brief had reportedly been pulled down. The facility's room placement had increased access to vulnerable residents by moving R1 from room D12-1 to room B92, directly across from their known victims' room. During an interview on 10/29/2024 at 12:00 p.m., CNA BB stated they were working the 3:00 p.m. through 11:00 p.m. shift on 5/13/2024 when they found R1 in bed with R2 while R3's brief had been pulled down. CNA BB stated that R1 had just his brief on while the resident lay in bed with R2. CNA BB added that R2 was fully clothed when R1 was observed in bed with her. CNA BB stated they redirected R1 out of the room and notified Charge Nurse DD of her observation. During an interview on 10/29/2024 at 1:48 p.m., Social Worker CC stated she was not made aware of the possible sexual abuse incidents involving R1, R2, and R3. Social Worker CC confirmed she had moved R1 on 5/1/2024 due to roommate conflicts. Social Worker CC stated she would not have made the switch had she known about the sexual abuse allegation involving R1 and R3. During an interview on 10/29/2024 at 3:16 p.m., Charge Nurse DD stated she was the Charge Nurse on duty during the two incidents (referring to the incident dated 4/11/2024 and the incident dated 5/13/2024). Charge Nurse DD stated after CNA HH and CNA BB alerted her to finding R1 in a compromised position relative to R2 and R3. During an interview on 10/30/2024 at 9:10 a.m., the Administrator stated the facility's protocols were not followed on how the inappropriate sexual contact involving R1, R2, and R3 were handled. The Administrator further revealed several opportunities were missed, including but not limited to immediate head-to-toe assessment, obtaining written statements from staff, interviews with cognitive residents, law enforcement notification in the event sexual abuse was confirmed, incident report on all vulnerable residents to rule out sexual abuse as well as having an interdisciplinary meeting to revise the care plans for the affected residents with consideration for room placement. The Administrator stated all the enumerated opportunities did not happen but should have happened. During an interview on 10/30/2024 at 9:45 a.m., the Director of Nursing (DON) stated she was not employed at the facility at the time of the incidents. The DON stated her expectation after sexual abuse was suspected or observed was that a head-to-toe assessment would be done immediately and results documented to rule out sexual abuse. The DON added that written statements would be obtained from staff immediately versus the following day, and 15-minute safety checks would be started immediately versus the following day. The DON further stated that law enforcement would be notified if sexual abuse was suspected. During an interview on 10/30/2024 at 10:30 a.m., the Medical Director stated he was not notified of the incidents until the next day and was not available to examine the residents personally. The Medical Director emphasized the importance of evaluating residents to rule out sexual abuse, given the compromised positions they were found in. The Medical Director added that the facility's decision to move R1 closer to the victims demonstrated poor judgment.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled Transmission-Based (Isolation) Precautions, and Smoking Policy-Residents, the facility failed to allow four of 11 residents (R) (R38, R22, R61, and R65) who desired to smoke and had a positive Covid-19 test, the choice to continue smoking while on isolation. Findings include: A review of the policy titled Transmission-Based (Isolation) Precautions, implemented date 2/9/2024 revealed the Policy Explanation and Compliance Guidelines section line numbered 4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. A review of the policy titled Smoking Policy-Residents, with a revised date of October 2023 revealed the Policy Interpretation and Implementation section line numbered 19. If the facility policy changes to one that prohibits smoking, residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. 1. A review of R38's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating intact cognition). A review of the care plan revealed a problem area of I am a smoker, onset 5/23/2023, reviewed 9/6/2023. Interventions included, I will allow nursing staff to keep cigarettes and lighters in a secure place, I will smoke in the designated smoking area, I will smoke at designated smoking times, I am to wear a smoking apron. A review of R38's clinical record revealed R38 tested positive for Covid-19 on 2/5/2024. During an observation tour on 2/9/2024, at approximately 8:15 am, R38 could be heard out in the hallway yelling from inside his room, Get me out of this room! In an interview on 2/9/2024 at 9:40 am, R38 revealed he had not been allowed to leave his room to go outside for smoke breaks after testing positive for Covid-19. During the interview, Licensed Practical Nurse (LPN) II informed R38 that he knew he had been told he could not go out to smoke as long as he had Covid-19, that he was on isolation, and had been instructed he could not leave the room. In an interview on 2/11/2024 at 8:20 am, Certified Nursing Assistant (CNA) AA confirmed R38 smoked. CNA AA further revealed that residents who are on isolation are not allowed to come out of their rooms, and they are not allowed to go out for smoke breaks because they are on isolation. 2. A review of R22's Quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS score of 14 (indicating intact cognition). An interview on 2/11/2024 at 8:28 am with R22 confirmed she smoked, and she stated she had been allowed to smoke in the past, but not lately. R22 revealed staff told her she couldn't come out of her room. A review of the facility-provided list of residents who smoke revealed that R22 was on the list. A review of the facility-provided list of residents with a Covid-positive test revealed that R22 was on the list. 3. A review of R61's Quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS score of 11 (indicating moderate cognitive impairment). An interview on 2/11/2024 at 8:55 am with R61 confirmed he smoked and was not allowed to go out for smoke breaks or leave his room. A review of the facility-provided list of residents who smoke revealed that R61 was on the list. A review of the facility-provided list of residents with a Covid-positive test revealed that R61 was on the list. 4. A review of R65's Quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS score of 15 (indicating intact cognition). In an interview on 2/11/2024 at 9:10 am, R65 confirmed he smoked, and he wanted to smoke but had not been able to in a week because he had been on lockdown. R65 revealed he was going to be able to smoke today, he was smiling and when asked if he was glad, R65 grinned and stated yes. A review of the facility-provided list of residents who smoke revealed that R65 was on the list. A review of the facility-provided list of residents with a Covid-positive test revealed that R65 was on the list. A review of the facility-provided list of residents with a Covid-positive test and a review of the facility-provided list of residents who smoke revealed that 11 of the 15 residents who smoke had a positive Covid-19 test and were on isolation. A review of the facility-provided list of residents who smoke revealed that smoking times were scheduled for 9:30 am, 11:30 am, 1:30 pm, 3:30 pm, 6:45 pm, and 8:30 pm. A tour of the designated smoking area identified no problems. In an interview on 2/9/2024 at 9:00 am during the initial tour of the facility and resident screening, LPN II revealed that residents on isolation were not allowed to go out for smoke breaks because they were on isolation and were not allowed to come out of their room. In an interview on 2/11/2024 at 8:45 am, CNA DD confirmed some residents smoked, and those residents normally went out to smoke several times a day. She confirmed that while on isolation, residents were not allowed to go to smoke breaks because they were not supposed to leave their rooms. In an interview on 2/11/2024 at 9:00 am, CNA EE confirmed this was a smoking facility and some residents smoked. CNA EE revealed if residents had Covid-19 they could not come out of their rooms and were not allowed to go out and smoke while on isolation. In an interview on 2/11/2024 at 9:05 am, CNA FF confirmed some residents smoked, they had several smoke breaks, and further confirmed the smoke break times were 9:30 am, 11:30 am, 1:30 pm, 3:30 pm, 6:45 pm, and 8:30 pm. She revealed that R65 usually went out to smoke but was currently not allowed to because he was on isolation. She further stated residents were not supposed to come out of their rooms when on isolation. In an interview on 2/11/2024 at 9:15 am, the Administrator confirmed residents who tested positive for Covid-19 were to be isolated inside their rooms. She confirmed they had several residents who smoked, they were provided smoke breaks, and that residents were allowed to smoke. She further revealed she was unable to give information on whether Covid-19 positive residents were allowed to go out for smoke breaks, or how many residents who smoke were in isolation and had been denied going outside to smoke. She stated her expectation was that the surveyor needed to talk with the Director of Nursing (DON) because that was a nursing issue. The DON was unavailable for an interview. In an interview on 2/11/2024 at 9:20 am, the Assistant Director of Nursing (ADON) confirmed some residents were allowed to smoke and were provided smoke breaks. She verified the assigned times for residents to have a smoke break as 9:30 am, 11:30 am, 1:30 pm, 3:30 pm, 6:45 pm, and 8:30 pm. She stated that Covid-positive residents on TBP were not allowed to leave their room except for medically necessary reasons only, and they must wear a mask. She stated the facility had plenty of staff to take care of their residents, and further stated they could let the Covid-positive residents who smoke go out together and social distance. She confirmed there had been no interventions put in place for the residents who smoked to aid them while not being allowed to smoke. She further stated she expected the staff to follow policy.

Based on observations, resident and staff interviews, review of facility documents, and review of the facility's policy titled Transmission-Based (Isolation) Precautions, the facility failed to ensure infection control practices were followed to prevent transmission and spread of Covid-19, related to staff entering and exiting three resident rooms on C Hall without donning proper personal protective equipment (PPE) and failing to close the door of two Covid positive resident's rooms during care. The facility was in an outbreak, with 44 residents and 13 staff tested positive for Covid-19, including 13 of the 15 residents residing on C hall. This deficient practice had the potential to spread Covid-19 infection to other residents residing in the facility, staff, and visitors. The sample size was 27 residents. Findings included: A review of the policy titled Transmission-Based (Isolation) Precautions, implemented 2/9/2024, revealed the Definitions section stated: Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. The section titled Policy Explanation and Compliance Guidelines stated 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the Center for Disease Control (CDC), for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used. Observation on 2/11/2024 at 8:32 am revealed a housekeeping staff exiting resident Room A-7. She removed her gown and gloves and discarded them into the trash receptacle on her cart. She used hand sanitizer in the hallway and was not observed to change her mask or face shield. She placed a Wet Floor-Caution stand in room A-7 doorway, left the door open, pushed her cart to the nurses' station, and removed her face shield. She was not observed to change her mask. Observation on 2/11/2024 revealed staff passing breakfast meals in disposable compartment trays. Room A-7 door was observed to be left open from 8:32 am to 8:42 am. Observation revealed there was not a trash container in Room A-7. Certified Nursing Assistant (CNA) CC was observed exiting the room with only a mask and face shield on and returned to the dietary department to get the next breakfast tray. She was not observed to change her mask or clean her face shield. Observation of the signage located beside the door of Room A-7 read STOP, Droplet Precautions, STOP. Everyone must clean their hands before entering the room and when leaving the room. Make sure eyes, nose, and mouth are fully covered before room entry, OR remove face protection before room exit. PPE: Gown, mask, goggles or face shield, gloves. Use safe work practices to protect yourself and limit the spread of contamination. (CDC). In an interview on 2/11/2024 at 8:40 am, CNA CC confirmed she removed her PPE and placed it inside a trash can before exiting Room A-7. She confirmed she did not remove her mask or face shield and stated face shields could be cleaned and reused. Staff were not observed cleaning face shields or changing masks when exiting rooms. Observation on 2/10/2024 at 8:27 am revealed LPN AA entered Room C-2 wearing a mask, but without donning (putting on) other PPE, and administered medications to a resident sitting in a wheelchair next to bed A. Further observation revealed LPN AA left the room, went to the medication cart, returned to room C-2, and exited the room. She was not observed to perform hand hygiene or close the resident room door during the observation. Observation revealed Room C-2 to have signage beside the door that read: STOP, Droplet Precautions, STOP. Everyone must clean their hands before entering the room and when leaving the room. Make sure eyes, nose, and mouth are fully covered before room entry, OR remove face protection before room exit. PPE: Gown, mask, goggles or face shield, gloves. Use safe work practices to protect yourself and limit the spread of contamination. (CDC). Observation on 2/10/2024 at 8:38 am revealed the call light for Room C-1 came on and LPN AA went to the room, knocked on the door, stuck her head inside the door, and asked the resident what she needed, then entered the room. The nurse did not don PPE before entering the room. Observation revealed signage beside the door of Room C-1 read: STOP, Droplet Precautions, STOP. Everyone must clean their hands before entering the room and when leaving the room. Make sure eyes, nose, and mouth are fully covered before room entry, OR remove face protection before room exit. PPE: Gown, mask, goggles or face shield, gloves. Use safe work practices to protect yourself and limit the spread of contamination. (CDC). Observation on 2/10/2024 at 8:42 am revealed LPN AA entered Room C-3 without donning PPE. When she exited the room, an interview at that time with LPN AA revealed she didn't have direct contact with a resident so didn't have to wear PPE. She stated that CNAs have direct contact with the residents, so they must wear PPE. LPN AA stated that when passing medications, she was not in direct contact, so she didn't need to wear PPE. Observation of the signage beside the door of Room C-3 read: STOP, Droplet Precautions, STOP. Everyone must clean their hands before entering the room and when leaving the room. Make sure eyes, nose, and mouth are fully covered before room entry, OR remove face protection before room exit. PPE: Gown, mask, goggles or face shield, gloves. Use safe work practices to protect yourself and limit the spread of contamination. (CDC). In an interview on 2/11/2024 at 8:45 am, CNA DD confirmed staff must wear PPE to enter isolation rooms and remove it before coming out. Observation on 2/11/2024 at 8:50 am on C Hall revealed staff who were delivering breakfast trays to residents in rooms with droplet precautions signage next to the doors were exiting resident rooms without changing or cleaning their face shields. An interview on 2/11/2024 at 9:00 am with CNA EE confirmed that staff must put on a gown, gloves, face shield, and mask to go in the room while residents are on isolation and must remove and discard the PPE and use hand sanitizer when they come out. In an interview on 2/10/2024 at 11:25 am, the Assistant Director of Nursing (ADON) revealed staff had been educated on donning and doffing (removing) PPE when entering and exiting isolation rooms. She confirmed that all staff should don proper PPE before entering Covid isolation rooms regardless of what care is being performed and doff when exiting. She confirmed that nurses should wear full PPE to enter Covid isolation rooms to administer medications or answer call lights and should doff before exiting. She stated her expectation was for nurses to wear full PPE to administer medications to residents on transmission-based isolation. In an interview on 2/10/2024 at 1:25 pm, the Administrator confirmed that anyone entering Covid-positive resident rooms should wear proper PPE. The Administrator stated staff should don proper PPE per the type of isolation before entering, doff the PPE before exiting the room, and sanitize their hands before coming out of any Covid-positive room. The Administrator revealed when the facility had an outbreak, she had re-educated the staff on wearing PPE. She revealed there were signs on every resident room door to notify anyone entering that they should never go in without wearing the proper PPE and her expectation was for staff to don and doff PPE as indicated on the signage.

Based on record review, staff interviews, and review of the facility policy titled Admission Criteria, the facility failed to complete a new Pre-Admission Screening and Review (PASRR) Level II after admission to the facility for one resident (R) R21. This had the potential to adversely affect one of three residents reviewed with a qualifying psychological diagnosis. Findings include: A review of the undated facility policy titled Admission Criteria revealed: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disorders (ID), or related disorders (RD) per the Medicaid PASRR process. b. If the Level 1 screen indicates that the individual may meet criteria for a MD, ID, or RD, he/she is referred to the state PASRR representative for the Level 2 (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible or evident MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. R21 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. Current additional diagnoses included but were not limited to, paranoid schizophrenia, generalized anxiety disorder, and psychosis. A review of R21's quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section E-Behavior: Verbal towards others. Section N-Medications: Antipsychotic use during the review period. A review of R21's care plan included, but not limited to: At risk for wandering/elopement. Potential for behaviors related to a history of behaviors, rolls around on her floor, sexually inappropriate at times. She is manipulative. She will throw herself on the floor when she doesn't get her way. Resident to resident altercations. Refuse care at times. States she is pregnant. Resident has impaired cognition and communication related to her diagnosis of schizophrenia. Potential for psychotropic medication side effects. Displays verbally aggressive behavior: yelling, screaming, cursing, and threatening other residents. A review of R21's physician orders revealed orders that included: Valproic acid 250 milligrams (mg)/five (5) milliliters (ml) solution give 20 ml (1000 mg) by mouth (po) at bedtime (hs) for mood/seizure disorder. Sertraline 100 mg one tablet po daily (qd). Fluphenazine 5 mg tablet po qd for psychosis. Valproic acid 250 milligrams (mg)/5 ml solution 5 ml po two times a day (bid) for mood/seizure disorder. A review of the Electronic Medical Record (EMR) revealed a PASRR Level 1 dated 1/24/2020 did not identify the diagnosis of schizophrenia. An interview on 2/11/2024 at 8:30 am with the facility Business Office Manager (BOM) revealed residents who are admitted with a Level 1 PASRR that does not indicate a mental diagnosis will have a resubmission of the Level 1 PASRR to see if they qualify for a Level II PASRR. She indicated she thought they submitted another Level 1 PASRR after R21 was admitted and it did not trigger a Level II PASRR. She verified the resubmission was not in the electronic medical record or in her office file. A telephone interview on 2/11/2024 at 8:34 am with the Social Service Director (SSD) revealed she re-evaluates resident needs for a Level II PASRR after admission. She stated she based her re-evaluation on the resident's diagnoses and if they exhibit behaviors. In an interview on 2/11/2024 at 8:36 am, the Administrator revealed if a resident needs a Level II PASRR, she expects them to be re-evaluated for the resubmission of the Level 1 PASRR.

Based on observation, record review, interviews, and review of facility polices, the facility failed to ensure that all staff members use an alcohol-based hand rub for routinely decontaminating hands after resident care for three residents (R) (#31, #54, and #22); failed to wash/sanitize hands during wound care for one resident, R#76; and failed to wear/dispose personal protective equipment (PPE) appropriately for COVID-19 isolation rooms. The census was 78. Findings include: Review of the policy titled Handwashing (pg. 26, dated 2012) revealed the following: II. Waterless Handwashing Products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situation other than those listed under Handwashing . (when hand are visibly soiled or contaminated). An observation conducted on 1/18/2023 at 8:41 a.m. revealed Licensed Practical Nurse (LPN) GG exiting the room of R#31 and failed to use an alcohol-based hand rub after providing care for R#31. An observation conducted on 1/18/2023 at 8:57 a.m. revealed LPN FF exiting the room of R#54 and failed to use an alcohol-based hand rub after providing care for R#54. An observation conducted on 1/18/2023 at 12:21 p.m. revealed Certified Nursing Assistant (CNA) BB exiting the room of R#22 and failed to use an alcohol-based hand rub after providing care for R#22. An interview conducted on 1/18/2023 at 8:42 a.m. with LPN GG revealed they did not use an alcohol-based hand rub after providing care for R#31. They acknowledged they should have used the hand sanitizer provided for them by the facility. An interview conducted on 1/18/2023 at 8:58 a.m. with LPN FF revealed they did not use an alcohol-based hand rub after providing care for R#54. They acknowledged they should have used the hand sanitizer provided for them by the facility. An interview conducted on 1/18/2023 at 12:22 p.m. with CNA BB revealed they did not use an alcohol-based hand rub after providing care for R#22. They acknowledged they should have used the hand sanitizer provided for them by the facility. An interview conducted on 1/18/2023 at 4:42 p.m. with the Infection Control Nurse revealed that it is always her expectation that all staff members practice Infection Control techniques and practices. ICP Coordinator acknowledged that this did happen and will further educate her staff on proper Infection Control practices. An interview conducted on 1/18/2023 at 4:44 p.m. with the Administrator revealed that it is always her expectation that all staff members practice Infection Control techniques and practices. 46579 2. Record review revealed R#76 admitted to the facility on [DATE]. The resident had diagnoses that included pressure ulcers. Observation of wound care for R#76 on 1/18/2023 at 10:11 a.m. revealed Registered Nurse (RN)/Wound Care Nurse began by collecting the supplies needed and reviewing the physician orders. She donned personal protective equipment (PPE) and after entering the room, she washed her hands and applied gloves. She started with the left foot, removed the dressing, and then cleaned the wound. She removed her gloves and put on clean gloves without washing/sanitizing her hands. She then dressed the wound. She removed her gloves, washed her hands and applied clean gloves. She continued to do the treatment for the left hip, left buttocks, right foot, and right hip separately. Although she washed/sanitized her hands between each wound treatment. She did not wash/sanitize her hands between removing the dressing, cleaning the wound, and dressing the wound for each wound. During an interview on 1/18/2023 at 11:31 a.m. RN/Wound Care Nurse stated wound care is a clean procedure and there is no need to perform hand hygiene with each glove change. Interview with the Assistant Director of Nursing (ADON) on 1/18/2023 at 11:07 a.m. revealed that hand hygiene should be performed before and after care, after each resident contact, any time that gloves are removed, and when hands are visually soiled. She also revealed that hand hygiene could be either washing with soap and water or alcohol-based hand rub. Review of the policy titled Hand Hygiene dated 12/22/2022, revealed that Hand Hygiene is the general term for cleaning your hands with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Additional considerations included in the policy was the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the policy titled Wound Care dated 10/2010 revealed steps in the procedure: 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. 45811 3. Interview with LPN AA on 1/17/2023 at 10:00 a.m. revealed that staff members can go from room to room with the same gown on. They will need a face shield and N95 mask. To discard used gowns, take off the gown in the resident's room and put it in the staff box. If the staff member does not discard the gown in the resident's room, they can discard it in the shower room, which has a container for the contaminated linen and trash. Interview with the Infection Control Nurse on 1/17/2023 at 11:00 a.m. revealed for residents who are COVID positive, PPE includes gown, gloves, N95, and a face shield. Staff are to take gown and gloves off after each resident visit. Observation of CNA CC on 1/17/2023 at 1:20 p.m. revealed the CNA was passing out lunch to COVID positive residents on Unit C and she did not have on eye protection or a respiratory mask. During an observation of Unit C on 1/18/2023 at 9:00 a.m. revealed four supply carts were revealed to be on the unit outside of resident rooms. They were spaced out along the corridor between the rooms. Room C4 did not have isolation signs on the door. During an observation on 1/18/2023 at 9:10 a.m. of CNA BB on Unit C revealed he went room to room without changing his isolation gown. Observation on Unit C on 1/18/2023 at 9:12 a.m. revealed CNA DD did not have on a respirator mask, and she did not have on any gloves. CNA DD was sorting dirty dishes on the cart that were previously removed from the isolation rooms.

Based on observation, interview, and review of facility policy, the facility failed to ensure one medication, Levemir insulin, was available on the medication cart for one of eight residents (R) (#15) observed during medication administration. Findings include: During observation of medication administration on 1/18/2023 at 11:26 a.m., Licensed Practical Nurse (LPN) FF administered four units of Levemir insulin for R#15. The resident's blood sugar was 287. Upon inspection of the insulin bottle, it revealed that the container that the insulin was in was labeled Levemir for R#11. An interview with LPN FF on 1/18/2023 at 11:30 a.m. revealed that if medication was not available for a resident, she would just borrow the same medication from another resident. Interview with the Regional Nurse Consultant on 1/18/2023 at 11:50 a.m. revealed that if a medication was not available for a resident, the nurse is to call the physician to get an order to pull from the E-box and notify the pharmacy. Review of facility policy titled Medication Administration- General updated October 2022 revealed medications supplied for one resident are not to be administered to another resident.

Based on observations, interview, and policy review, the facility failed to ensure that it was maintained in a safe and comfortable home-like environment related to peeling paint and broken equipment in two of 78 resident rooms (D2 and D8) and one medication storage room on C hall. Findings include: Observation on 1/17/2023 at 10:35 a.m. revealed peeling/missing paint above the bumper behind D2-1 bed. Part of the bumper was loose. Observation on 1/17/2023 at 11:05 a.m. revealed there were mattresses, bed frames and some over bed tables outside the window of room D8. Observation on 1/18/2023 at 12:15 p.m. of the medication storage room behind C-hall nurses station revealed the sink in the medication room had the hot water knob broken and was laying in the sink. Further observation on 1/18/2023 at 3:08 p.m. revealed, in room D2-1 bed, the wall/paint above the bumper appeared to be repainted. The bumper was now hanging down from the wall. At 3:11 p.m., tables, mattresses, and bed frames remained outside under the window of room D-8. During an interview on 1/19/2023 at 10:15 a.m., the Maintenance Director stated he has been employed at the facility for [AGE] years. He verified the concerns identified during the survey. He stated there is a Maintenance Logbook at each nurse's station where staff write down things that need to be repaired or replaced. He stated that he checks the book every morning for his to do list. He stated that he tries to pay attention to the issues that affect the residents, but then will start to work on other things. He stated that he was working on the broken bumper rail in room D2, but staff keep pushing the bed up against it, so it keeps getting broken. He stated the broken items (bed, mattress, overbed tables) stored outside the window in room D8 should have been hauled off. He stated there is really no place to put things like that but stated it should not be at the resident's window. He fixed the broken faucet in the medication room, but stated staff do not use that sink, that they go to the bathroom or the clean utility room to wash their hands. He stated that he does not have a routine maintenance schedule of checking rooms, he just goes by the Logbook. A review of the policy titled Safe and Homelike Environment dated 12/19/2022 revealed the facility will provide a safe, clean, comfortable, and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents that sustained multiple falls. The QAA committee also failed to identify that their established policies for accidents were not being fully operationalized, and therefore failed to implement effective corrective actions to address the problems. In addition, the QAA committee failed to ensure that concerns with non- functioning call lights identified at the facility's last two (2) standard surveys on 02/12/15 and 06/20/14, and with pests cited during the last standard survey on 02/12/15 continued to be effectively monitored to prevent recurrence. The facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents. On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Nurse Consultant on 01/19/16 at 2:55 p.m. It was determined that the provider's non-compliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment or death to residents. The noncompliance caused actual harm to R#2, who sustained a laceration to the chin on 11/29/2015, a fracture to the nose on 1/14/2016; resident S who sustained a [MEDICAL CONDITION] on 6/9/2015, a shoulder fracture on 11/10/2015, and; to R#7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with documentation that the safety helmet was not in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K). In addition, Substandard Quality of Care (SQC) was determined to exist at 42.CFR 483.13 and 42.CFR 483.25. A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S-K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to inservice staff on monitoring of these rooms. The Immediate Jeopardy related to CFR 483.25 Quality of Care (F 323 S/S-K), CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K) was determined to be ongoing. Findings include: 1. Review of the citation text for tag F 463 written during the facility's standard survey on 02/12/15 noted that not all of the components of the call light system were fully functional, including rooms B-8-2, C-3, C-4, and C-8. Review of the citation text for tag F 463 written during the facility's standard survey on 06/20/13 revealed that not all of the components of the nurse call system were fully functional, including four rooms on the B-hall and two rooms on the C-hall. During observations for functionality of all call lights on Station 2 on 01/19/16 at 1:22 p.m., it was noted that there were a total of eight resident rooms and two of two common baths that did not have fully functioning call lights, including rooms B-8, C-3, C-4, and C-8 which were specifically cited on 02/12/15. During interview with the Administrator/QAA Coordinator on 01/29/16 at 11:11 a.m., she stated that call lights had been removed from QAA because most of the call light concerns cited during the standard survey were located on Station 1, and they got a new nurse call system for that unit. During further interview she stated that staff were supposed to fill out a work order if a call light was not working, and did not know how this process fell through. Upon further interview, she stated that the QAA committee had not recommended that the older call light system on Station 2 be monitored by maintenance more frequently. Cross-refer to F 463. 2. Review of the citation text for tag F 469 written during the facility's standard survey on 02/12/15 noted observations of ants and roaches in the solarium, A-hall, and D-hall. During multiple observations of the facility on 01/19/16 at 2:10 p.m., 5:49 p.m. and 5:54 p.m.; 01/25/16 at 9:05 a.m. and 11:55 a.m., insects with the appearance of ants and roaches were observed on the B- and C-halls, dining room, Station 1 nurse's station, and lobby. During a family interview with an unsampled resident on 01/19/16 at 10:49 a.m., they stated they had seen ants and roaches in the resident's room recently. During interview with resident R on 01/20/16 at 9:20 a.m., they stated they saw roaches in their room once or twice a week. During interview with the Administrator/QAA Coordinator on 01/29/16 at 11:11 a.m., she stated that pests were no longer in QAA, because their plan was for the pest control company to come out twice a month and as needed, and to implement a Pest Control book at the nurse's station. Cross-refer to F 469. 3. During interview with the Administrator/QAA Coordinator on 01/29/16 at 11:11 a.m., she stated that falls were discussed in the Safety Committee meetings, but was not presented in the QAA meetings. Upon further interview, she stated that the Assistant Director of Nurses (ADON) collected falls data such as location and time of day and presented it at the Safety Committee meeting to see if there was a pattern of falls, and that the data was an overall look at all resident falls but was not broken down to individual resident's falls. During further interview, she stated that individual resident falls were discussed in the Falling Star meetings, and there was nothing they felt that should have been taken to QAA as the fall stats were different every month. During interview with the facility's Medical Director on 01/26/16 at 11:35 a.m., he stated that he could not think of anything else other than a restraint to prevent resident #7 from falling, and that there were a lot of falls at all nursing homes. During further interview, the Medical Director stated that he occasionally attended the QAA meetings, but didn't attend more than he attended. Upon further interview, he stated that if he could not attend a QAA meeting, he reviewed the minutes and signed the attendance sheet. During interview with the Director of Nurses (DON) on 01/29/16 at 1:00 p.m., she stated that the Medical Director may arrive late to a QAA meeting or leave early, but that he was at every meeting and was given any information he may have missed. Review of the monthly QA Meeting sign-in sheets from February 2015 to December 2015 (no sheet provided for May 2015) revealed that the Medical Director signed as having attended each meeting. Review of the facility's Quality Improvement Principles policy and procedure revealed the following: We as a company will ensure that our processes or systems identify areas to improve the outcomes that will benefit all our staff and residents. The root cause of problems are not always easy to identify, but there are tools and exercises that teams can use, like cause and effect diagrams, brainstorming and flow charting, that can help our teams uncover the next step in order to truly address problems. Monthly QA/PI (Quality Assessment/Performance Improvement) meetings will be held to ensure the processes are on target and that our monthly triggers have been implemented and met. The QA committee will focus on identifying quality issues; address quality issues through development and implementation of corrective action plans; promote a culture of teamwork and empowerment processes; and identify pertinent issues and develop realistic action plans that result in improved outcomes and overall customer satisfaction. Process Improvement involves fact finding through data collection and root cause analysis to identify and measure the problem and its source. Once the source of the problem is identified, improvement comes through generating salutations (sic) that address the root cause of the problem. Despite the facility QAA policy which noted that root cause analysis would be done to identify problems, the QAA committee failed to determine that there was a concern with falls for seven (7) residents between March 2015 and January 2016, including one (1) resident (#7) who sustained twenty-one (21) falls during this time. Injuries for these seven (7) residents included fractures, lacerations, abrasions, hematomas and bruising. Cross-refer to F 323.

Based on observation, record review, and staff interview, the facility failed to be administered in a manner to ensure there was an effective falls program that determined the root cause of falls, failed to monitor the implementation and effectiveness of interventions to keep residents safe from falls, and failed to ensure the facility's falls policy was fully implemented. In addition, the facility failed to ensure that there was supervision to protect the residents in the facility from resident #7's aggressive behaviors. In addition, the facility failed to ensure there was sufficient staff to provide supervision to prevent falls, neglect, and pressure ulcers. In addition, the facility failed to effectively monitor the functionality of the nurse call system on one (1) of two (2) nursing units (Station 2). It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Registered Nurse Consultant on 01/19/16 at 2:55 p.m. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Registered Nurse Consultant were again notified that IJ existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K). In addition, Substandard Quality of Care (SQC) was determined to exist at 42.CFR 483.13 and 42.CFR 483.25. A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S-K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to inservice staff on monitoring of those rooms. The Immediate Jeopardy related to CFR 483.25 Quality of Care (F 323 S/S-K), CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K) was determined to be ongoing. The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/201 and a fracture to the nose on 1/14/2016; Resident S who sustained a [MEDICAL CONDITION] on 6/9/2015 and a shoulder fracture on 11/10/2015; Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. Findings include: 1. During review of Accident/Incident Monthly Tracking Logs and Nurse's Notes, it was noted that resident #7 was involved in nine resident-to-resident altercations between 04/12/15 and 01/21/16. During interview with the interim DON on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring of residents, and that staff and other residents would tell them where resident #7 was located. Review of Preadmission Screening and Resident Review (PASRR) and a geriatric behavioral health facility discharge information revealed recommendations for psychiatric assessment and care and follow-up with mental health. During interview with the Administrator on 01/28/16 at 10:30 a.m., she stated that the facility did not have a behavior management policy and procedure. During interview with the Social Services Director on 01/29/16 at 9:24 a.m., she verified that resident #7 had not been seen by a psychiatrist since September. Cross-refer to F 224. 2. During review of the Accident/Incident Monthly Tracking Log, Nurse's Notes, Falling Star Program Tracking Forms, and Incident/Accident Reports, it was noted that resident #7 had twenty-two falls between 03/14/15 and 11/27/15. During interview with the interim DON on 01/22/16 at 1:13 p.m. and 01/27/16 at 10:15 a.m., she verified that there was not enough information available in the accident investigations for many of resident #7's falls to be able to effectively determine the cause of the fall and/or if interventions were in place at the time of the falls. During interview with the Corporate Registered Nurse Consultant on 01/25/16 at 1:32 p.m., and with the Administrator on 01/29/16 at 11:11 a.m., they stated that falls were analyzed for all residents combined, but they did not analyze individual resident's falls that would help in determining a root cause. Review of facility documents revealed that Resident #2 had ten falls between 08/30/15 and 01/19/16. During interview with the interim DON on 01/22/16 at 1:30 p.m. revealed that staff had not determined the root cause of Resident #2's ten falls since 8/30/15 and that the resident's falls had occurred on different shifts. Continued interview revealed that she expected licensed nursing staff to notify certified nursing staff to monitor a resident more frequently if that resident had received a medication that caused potential sedation/drowsiness. Further interview revealed that she did not expect staff to follow the resident to other parts of the facility to monitor because the resident did not pose harm to other residents. Although review of Physical Therapist (PT) recommendations for restorative services for ambulation and transfers to prevent a decline after resident S was discharged from skilled PT on 04/05/15, the facility staff failed to provide those restorative services which may have possibly prevented the subsequent fall with [MEDICAL CONDITION] on 06/09/15. Further review of clinical records and observations during the survey revealed that interventions to prevent future falls for resident S, such as leaving the room door open for more effective monitoring and ensuring the resident's bed was maintained in a low position were not consistently done, as well as not updating the care plan to reflect these interventions. Interview with the interim DON and Assistant Director of Nursing (ADON) on 01/22/16 at 1:50 p.m., revealed that resident S was independent with ambulation and toileting when he/she was admitted to the facility, but was now bedbound and dependent on staff for bed mobility, transfer and toileting after the 06/09/15 fall with [MEDICAL CONDITION]. Continued interview revealed that staff were not inserviced after the 06/09/15 fall regarding any special interventions to prevent future falls. Continued interview with the interim DON and ADON revealed that the 11/11/15 fall with shoulder fracture was due to the resident transferring him/herself. Further interview revealed that staff had not determined the root cause of the resident's falls. Review of resident T's clinical record revealed they had a fall over the siderail on 12/07/15 that resulted in a lumbar compression fracture, with documentation that the bed was not in its lowest position at the time. However, staff failed to address the resident's fall over the siderail in order to effectively evaluate the continued use of the siderails as a potential hazard for the resident. During observations during the survey, it was noted the staff failed to consistently keep the resident's bed in its lowest position and failed to keep the call light within the resident's reach as care planned. During observation and interview with the interim DON on 01/29/16 at 8:55 a.m., she verified that resident T's bed was not in its lowest position, and that she was not aware that the siderails were a potential hazard for the resident. Cross-refer to F 323. 3. The facility failed to ensure that there was sufficient staff to ensure that resident #7 and the other residents in the facility were free from neglect to prevent altercations from resident #7's behaviors. In addition, the facility failed to provide sufficient staff to provide supervision to prevent accidents for seven residents (#2, #7, #13, #26, # 27, S, and T) and to monitor for the implementation and effectiveness of fall prevention interventions. In addition, the facility failed to ensure that there was sufficient staff to consistently monitor resident's skin weekly and implement preventive skin breakdown measures for two residents (S and #25) who developed unstageable pressure ulcers. When the ADON was asked on 01/29/16 at 9:45 a.m. how she ensured that staffing was sufficient to meet the residents' needs, she stated that she was not sure how to answer that question, and that residents were assigned to a group and a Certified Nursing Assistant (CNA) assigned to take care of residents in a group. Cross-refer to F 353. 4. The facility failed to ensure that the nurse call system on Station 2 with a known history of malfunctioning was not monitored more frequently in order to detect when the components of the system were not all fully functional, so that they could be repaired in a timely manner. During interview with the Administrator on 01/29/16 at 11:11 a.m., she stated that the Quality Assessment committee had not recommended the older nurse call system on Station 2 be monitored more often than monthly, as most of the concerns cited with the call light system on the previous survey were on Station 1. Cross-refer to F 463.

2.) On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Nurse Consultant on 01/19/16 at 2:55 p.m. It was determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The facility submitted a credible allegation o f compliance on 1/20/2016 5:25 p.m. alleging removal of the IJ. The facility remained out of compliance at a lower scope and severity of E while the call lights were repaired. Findings include: During the initial tour of the facility on 1/19/16 from 9:40 a.m. until 10:15 a.m., it was noted that there the nurse call signal light outside the rooms did not illuminate when the call button was pressed in rooms B-12 and B-6. During an interview with the Interim Director of Nursing on 1/19/2016 at 12:00 p.m., she stated that the call light system in Station One had been replaced in September of 2015 and she was unaware of any problems with resident call lights. During the continued interview she revealed that when call lights are being repaired residents are given bells to summon staff. During the interview, she stated that that maintenance staff check all call lights for function regularly if staff become aware of a non-functioning light, they notify maintenance staff by completing a repair requisition. During a tour of the B and C halls conducted with the Maintenance Director on 1/19/16 from 1:22 p.m. until 1:30 p.m., the surveyor and Maintainence Director tested the call lights by pressing the call bell and observing to see if the lights illuminated over the door There were no functioning lights observed above rooms B-6, B-12, C-5, C-6, C-8, C-3, and C-2. There was no call light cord in room C-4, and the cord was removed from the resident ' s drawer and inserted into the wall by the maintenance director. The common bath in C hall revealed that only one of two lights located in the shower area would cause the light above the door to illuminate. When the call bell was pulled in the common bath in C hall, the indicator light did not illuminate in the nurses' station panel. The call system panel at the nurse s station was tested during the tour. The indicator lights in the panel that would have alerted the staff that a resident needed assistance did not light for the following rooms: B-6, B-8, C-2, C-6, and C-8. There was no indicator light for the common bath in C hall and There was no audible alert in the system that would have notified staff that a resident needed assist. The panel was located over the nurses ' heads, and not immediately visible to staff sitting at the nurses ' station unless they looked up. An interview was conducted with CNA FF on 1/19/2016 at 1:40 p.m. FF revealed that he watches for resident call lights over their doors, and that most of them are working. If they do not work, maintenance repairs them. An interview was conducted with LPN CC on 1/19/2016 at 1:43 p.m. CC confirms that there is no audible alert on the nurses ' station call panel. She did not know how long the lights at nurses ' station call panel had not been working. She states that staff members are in the halls and monitor lights. An interview was conducted with LPN GG on 1/19/2016 at 1:45 p.m. She revealed that the residents do not use their call lights very often; most of them find the nurse if they need something. GG states Certified Nursing Assistants (CNAs) round on the residents. During interview with the facility's Maintenance Director XX on 01/19/16 at 12:35 p.m., he stated that the last time he checked all the call lights was about two weeks ago, and the only problems he had was with two call light triggers that had to be replaced in room B-7 and B-8. Upon further interview, he stated that the call light system on the B- and C- halls (Station 2) was obsolete, and they could not get parts to repair it unless it was something small like a bulb. Maintenance Director XX further stated that when he checked call lights, he activated both the bathroom and bed call lights in all of the rooms, and had an assistant that verified the light came on at the nurse's station and in the hall. During interview with Maintenance employee YY at this time, he stated that all call lights were checked monthly at the end of the month. Review of the Call Light System Rounds forms from 02/27/15 to 12/28/15 revealed that no concerns were documented for any of the forty-four rooms checked monthly. During observation on 01/19/16 at 2:10 p.m., call lights on the B-hall could not be visualized when sitting at the Station 2 nurse's station, and staff would have to lean over the desk to be able to visualize any call lights activated on the C-hall. During interview on 01/19/16 at 5:15 p.m. with a contractor called by the facility to check the call light system on Station 2, he stated that he found eight bad bulbs that he replaced in the console at the nurse's station. Upon further interview he stated that the nurse call system was very old. During observation and interview with Corporate Vice President VV on 01/19/16 at 5:20 p.m., he verified that the call light in the commode area of the C-hall Central Bath would only flicker once or twice at the nurse's station before going out when activated. During interview on 01/19/16 at 5:35 p.m., the Corporate Vice President VV stated that the nurse call system on Station 2 was not designed with an audible alarm. During interview with Maintenance Supervisor YY on 01/20/16 at 8:30 a.m., he verified that when the Central Bath light on the B-hall was activated, that it did not light up on the console at the nurse's station. During interview with Certified Nursing Assistant (CNA) PP on 01/21/16 at 6:56 a.m., she verified that she could not see call lights on in the hallway on one hall if she was on the other hall on Station 2. Upon further interview, she stated that she was aware of the call system not working at times for months, and would fill out a work order slip when something was not working. Review of Maintenance Repair Requisitions from November 2015 to the present time revealed none were seen related to non-functioning call lights. Review of the citations written during the last two standard surveys on 02/12/15 and 06/20/13 revealed that F 463 was written both times related to not all components of the call light system being functional, including on Station 2. During interview with the Administrator on 01/29/16 at 11:11 a.m., she stated that staff were supposed to fill out a work order if a call light was not working, and did not know how this process fell through. Upon further interview, she stated that the Quality Assurance and Assessment Committee had not recommended for the older call system on Station 2 be monitored more often than monthly, despite concerns with the call light system on the previous two surveys.

Based on observation, clinical record review, and staff interview, the facility failed to ensure that there was sufficient staff to provide supervision to protect potentially all residents in the facility from aggressive behaviors of resident #7, as evidenced by nine (9) resident-to-resident altercations between 04/12/15 and 01/21/16. In addition, the facility failed to ensure sufficient staffing to prevent falls, and to monitor that interventions for falls prevention were implemented and re-evaluated for continued use for seven (7) residents (residents #2, #7, #13, #26, #27, S, and T), who sustained injuries including fractures, lacerations, hematomas and abrasions. In addition, the facility failed to ensure there was sufficient staff to monitor residents' skin weekly as per policy, and implement measures to help prevent the development of pressure ulcers for two high- risk residents (S and #25), who developed deep tissue injuries. The facility's failure to have sufficient staff resulted in Immediate Jeopardy (IJ). It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The sample size was thirty (30) residents. On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that IJ existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Registered Nurse Consultant on 01/19/16 at 2:55 p.m. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Registered Nurse Consultant were again notified that IJ existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K). In addition, Substandard Quality of Care (SQC) was determined to exist at 42.CFR 483.13 and 42.CFR 483.25. A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S-K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to inservice staff on monitoring of those rooms. The Immediate Jeopardy related to CFR 483.25 Quality of Care (F 323 S/S-K), CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K) was determined to be ongoing. Findings include: 1. The facility failed to ensure that potentially all of the residents in the facility were free from neglect by not providing the staff supervision necessary to ensure the safety of the residents from the aggressive behaviors of resident #7. Review of Accident/Incident Monthly Tracking Logs, Incident Reports, and Nurse's Notes revealed that resident #7 was involved in nine resident-to-resident altercations between 04/12/15 and 01/21/16. Review of resident #7's care plan interventions included to place her where constant observation was possible and not leave unattended; check frequently on rounds; and to increase rounds to prevent risk of unwitnessed falls and injury. The lack of compliance to protect both resident #7 from unsafe behaviors, as well as the other residents from injury from resident #7's aggressive behaviors included a [MEDICAL CONDITION] for resident #7 when she fell attempting to hit another resident, and black eye resident #7 obtained when she was hit by another resident, as well as scratches for resident #23 and an unsampled resident. During interview with the DON on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring for residents, and that if resident #7 was moving about the facility that they relied on staff and other resident to tell them where she was. Cross-refer to F 224. 2. The facility failed to ensure there was sufficient staff to provide supervision to prevent accidents, and to ensure that staff were knowledgeable at all times about the needs of the residents as evidenced by inconsistent implementation of care plan interventions for falls and re-evaluation of interventions to ensure they were appropriate and effective. Review of Accident/Incident Monthly Tracking Logs, Incident Reports, and Nurse's Notes revealed the following falls: Resident #2: There were a total of ten falls between 08/30/15 and 01/10/16. Injuries sustained included a nose abrasion, chin laceration, nose fracture. Resident #7: There were a total of twenty falls, plus two more falls related to either attempting to hit another resident or being pushed down by another resident, between 03/14/15 and 11/27/15. Injuries sustained included a fractured arm; [MEDICAL CONDITION]; abrasions; bruising and skin tears. Resident #13: There were a total of five falls between 07/21/15 and 12/07/15. Injuries included skin tears, abrasion, and laceration. Resident #26: There were five falls between 12/28/15 and 01/18/16 with injuries including [MEDICAL CONDITION] and hematoma. Resident #27: There were a total of twelve falls between 03/16/15 and 11/08/15, with a head injury. Resident S: There were a total of three falls between 05/27/15 and 11/10/15. Injuries sustained included abrasion, laceration, [MEDICAL CONDITION], and shoulder fracture. Resident T: There were a total of two falls between 06/29/15 and 12/07/15, one with a lumbar compression fracture. Cross-refer to F 323. 3. The facility failed to ensure that there was enough staff to consistently complete weekly skin assessments done by nurses, as well as implement measures to prevent the development of pressure ulcers for two residents at high risk for skin breakdown (residents S and #25). Review of the clinical records for these residents revealed that resident S and #25 developed deep tissue injuries to the heel, and did not have any interventions in place to help prevent the pressure ulcers nor skin assessments done by a nurse prior to the development of the wounds. In addition, the facility failed to perform skin assessments by a nurse for two weeks prior to the development of two Stage II pressure ulcers for resident #7. Cross-refer to F 314. 4. The facility failed to have sufficient staff to ensure the comprehensive care plans were revised for three of nine residents reviewed for falls (residents #2, #7, and S), to include falls prevention and monitoring interventions for these three residents with multiple falls with injury. Cross-refer to F 280. 5. The facility failed to have sufficient staff to ensure the comprehensive care plan interventions were consistently followed including the following: Cross-refer to F 323: -A chair alarm and safety seat belt not intact for residents #26 and #27. -A bed alarm for residents #7 and #27 not intact. -The bed was not in lowest position and call light not in reach for resident T. -A safety helmet and to ensure proper footwear at all times for resident #7 not consistently followed. -Assist on smoke breaks for resident #7 documented as not done on one occasion. Cross-refer to F 314: -Weekly skin assessments not done by a nurse prior to the development of deep tissue injuries for residents #25 and S, and prior to the development of two Stage II pressure ulcers for resident #7. -Cushion in the seat of the wheelchair for resident #7 not intact. Cross-refer to F 224: -Instruct staff to stay with resident (#7) if she is wandering off the unit. Cross-refer to F 250: -Psych consult as needed for resident #7. During interview with the Assistant Director of Nurses (ADON) on 01/29/16 at 9:45 a.m., who scheduled the nursing staffing for the facility, she stated that she was not sure how to answer how they ensured that staffing was sufficient to meet the residents' needs. She stated that residents were assigned to a group, and then Certified Nursing Assistants (CNA) were assigned to a group to care for them. Upon further interview, she stated that she included herself and the Director of Nurses (DON) in the calculation of direct care nursing hours, but that they were administrative staff and did not do direct care.

Based on observation, clinical record review, facility policy and procedure review, and resident and staff interview, the facility failed to provide supervision to prevent accidents; failed to do thorough investigations to determine the root cause of falls; failed to monitor and re-evaluate interventions put in place after a fall; and failed to assess for the appropriate use of a seat belt and side rails. This failure resulted in falls with injuries including fractures, lacerations, hematomas and abrasions for seven (7) of nine (9) residents reviewed for falls (residents #2, #7, #13, #26, #27, S, and T), on a total sample of thirty (30) residents. The facility's failure to have an effective falls program resulted in immediate jeopardy (IJ) as evidenced by a right arm fracture, head lacerations and abrasions; hip abrasions; and black eyes for resident #7; laceration and broken nose for resident #2; broken left hip and right shoulder for resident S; lumbar fracture for resident T; and hematoma to the head for resident #13. The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/2015 and a fracture to the nose on 1/14/2016; Resident S who sustained a fractured hip on 6/9/2015 and a shoulder fracture on 11/10/2015; to Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. IJ was identified on 01/26/16, and the facility Administrator and Corporate Nurse Consultant were notified at 2:01 p.m. IJ was determined to exist as of 03/14/15. The IJ also determined that the provider's non-compliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment or death to residents. The IJ was related to non-compliance with Quality of Care (F 323 S/S-K). The IJ was determined to be ongoing. Findings include: 1. Review of Resident #7's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had short- and long-term memory problems, and severely impaired cognitive skills for decision making. Further review of the MDS revealed that she needed extensive assist by one staff for walking in the room and hall; limited assist by one staff for locomotion on and off the unit; extensive assist by one person for toilet use and transfers; and that her balance during transitions and walking was not steady and only able to stabilize with human assistance. Review of the risk for falls care plan with an onset date of 01/13/16 revealed interventions that included to place the resident in an area where constant observation was possible; apply safety helmet at all times and replace when resident removed; assist resident during smoke breaks; analyze previous falls by resident to determine whether pattern/trend can be addressed. Further review of this care plan revealed no intervention listed for a seat belt or bed alarm. Review of a Fall Risk Evaluation dated 11/30/15 revealed that she had a total score of 26 (anything above a 10 was considered high risk). Review of Physician's Orders revealed that there was no order for a seat belt while in the wheelchair. During observation in the restorative dining room on 01/20/16 at 7:45 a.m., resident #7 was observed to have a clip-type seat belt on while in the wheelchair. This was verified during interview at this time with Licensed Practical Nurse (LPN) MM. During observation in the resident's room on 01/20/16 at 1:45 p.m.; 1/21/16 at 6:43 a.m., 9:18 a.m. and 11:15 a.m.; no bed alarm was seen. During interview with Certified Nursing Assistant (CNA) PP on 01/21/16 at 6:56 a.m., she stated she knew which residents were fall risks by looking at their Activity of Daily Living (ADL) sheet. During further interview, she stated that resident #7 was a fall risk, and could walk but she was unsteady. Review of the CNA's ADL sheet initiated 01/18/12 and last reviewed on 08/29/15 noted that it contained interventions for a bed and chair alarm, and that a helmet was to be on at all times. During interview with CNA EE on 01/21/16 at 10:45 a.m., she stated that she had seen resident #7 throw herself out of the wheelchair several months ago, and one time when she did this the wheelchair turned on top of her and the seat belt broke. During interview with CNA EE on 01/21/16 at 11:22 a.m., she stated that resident #7 did not have a bed alarm, and that they kept her in a place where they could monitor her and keep her occupied. During observation of the resident in the wheelchair on 01/22/16 at 10:30 a.m., a chair alarm was noted on the back of the wheelchair, but it was not clipped to her clothing, and there was no seat belt. This was verified during interview with CNA JJ on 01/22/16 at 10:49 a.m., who stated the chair alarm was discontinued when the seat belt was applied. During interview with Restorative CNA OO on 01/25/16 at 9:06 a.m., she stated that she and another Restorative CNA applied and checked the functionality of alarms every day but Sunday. Review of the Daily Safety Alarm Check for January noted that a bed alarm and chair alarm was functioning properly on 01/20/16 and 01/21/16 (noted observations above where no bed alarm was seen). During observation on 01/25/16 at 9:18 a.m., a chair alarm was noted on the back of resident #7's wheelchair, but it was not clipped to her clothing. Review of her Nurse's Notes, Incident/Accident (I/A) Reports, and Falling Star Program Tracking forms revealed that resident #7 sustained the following falls from March, 2015 to the present time. Noted in the parentheses are comments related to lack of investigation following the fall, or failure to have an intervention in place when the fall occurred: On 03/14/15 at 1:00 p.m.: The I/A Report noted the resident was brought out of the dining room due to agitated behavior, and while walking down the hall she dropped to the floor and began banging her head on the floor causing a gash in the the top of her head, and she was sent to the emergency room (ER). The Additional Comments section to prevent recurrence noted to make sure the resident had a helmet on at all times. (There was no documentation as to why the resident was in the dining room without a helmet on). On 03/23/15 at 9:15 a.m.: Resident #7 was found with an abrasion to her left hip, and the resident stated she fell twice while outside in the smoking area. Resident encouraged to be more aware of her surroundings. Staff to assist resident to and from the smoking area due to unsteady gait and non-compliance with wearing helmet. (There was no documentation that an investigation was done as to how the resident got outside unattended). On 04/12/15 at 6:05 a.m.: When attempting to hit another resident in the dining room, resident #7 lost her balance and fell backwards, causing a laceration to the back of her head. Plan to redirect resident when agitated, and give as needed (prn) medication for agitation. Sent to ER. (There was no documentation if the helmet was on). On 04/14/15 at 11:30 a.m.: Resident was sitting in chair in dining room, fell asleep and fell from chair onto floor. Plan to encourage and assist resident to her room to lie down once meal is complete or upon first sign of sleep. On 06/05/15 at 11:40 a.m.: Resident crying and stated she fell and hurt her back. Send to ER for evaluation. PT to screen and treat as indicated. (There was no indication that an investigation was done as to where or how the resident fell ). On 06/15/15 at 1:15 p.m.: Ambulating in dining room, fell to floor. Dining room staff to monitor more closely related to unsteady gait, poor safety awareness, medication regimen, behavior of throwing self to floor. Continue to encourage resident to wear safety helmet at all times. (There was no documentation as to why the resident was in the dining room without a helmet on). On 07/10/15 at 11:30 p.m.: Noted ambulating in hallway and she tripped and fell to floor hitting right side of head on floor causing a hematoma. Ensure resident is wearing proper footwear. Sent to ER. A witness statement was obtained from a CNA who wrote that she saw the resident walking up the hall and the next thing she fell . (There was no documentation as to why the resident did not have proper footwear on despite an intervention for properly fitting non-skid shoes for ambulation). On 07/20/15 at 11:00 a.m.: Resident was ambulating in another resident's room and tripped over her foot, shoes not tied. Make sure resident is wearing proper footwear. Shoe laces put into resident's shoes. (There is an intervention to place the resident in an area where constant observation is possible. Also, there was no documentation as to why she did not have on proper footwear). On 08/12/15 at 8:30 a.m.: Resident #7 found in dining room with an abrasion to left side of forehead and face. A male resident reported that resident #7 fell in the Station 2 lobby and hit her head on the floor. Staff will try to encourage resident to go to room and relax if agitated or to reward resident with snack. Wear proper fitting shoes. Give prn med for agitation. (There was no documentation as to why encouraging the resident to go to her room if agitated was an intervention if the fall was unwitnessed. There was no documentation as to why proper footwear was not on). On 08/13/15 at 12:00 p.m.: Resident walking up B-hall, let go of railing and fell to floor receiving an abrasion to the back of her head. Give prn med for increased agitation. Ensure wearing helmet and proper fitting shoes. Sent to ER. There was no documentation as to why the helmet and proper footwear were not on). On 09/06/15 at 11:30 a.m.: Resident on floor in dining room said another resident pushed her down. Encouraged both residents to keep hands to themselves. On 09/12/15 at 2:35 p.m.: Resident found sitting on the floor in her room with a laceration to the back of her head, hat by her side. Sent to ER. Do every two hour room checks. (There was no documentation of investigation done to try and determine how she fell ). On 09/14/15 at 4:30 p.m.: Resident in room ambulating and fell to floor on buttocks. Helmet on. Therapy to work with resident on ambulation and balance. All staff to observe resident hourly until bedtime to prevent recurrence. (There is no care plan intervention for hourly monitoring. During interview with CNA EE on 01/21/16 at 11:22 a.m., she stated she made rounds every two hours). On 09/22/15 at 4:10 a.m.: Resident fell and hit the back of her head on the bed while trying to pull her pants up. No sock on left foot. Staff witnessed the fall. Staff will assist resident with clothes and dressing. Sent to ER. (The resident was assessed on the Quarterly MDS dated [DATE] to be extensive assist by one staff for dressing). On 09/23/15 at 12:15 a.m.: Seen by staff throwing herself to the floor in the hallway hitting her right forehead. Sent to ER. Two witness statements taken noted they observed the resident come out of her room and throw herself to the floor head first. Add bed alarm so staff will know when she gets out of bed. On 10/07/15 at 3:25 p.m.: Noted on floor on A-hall, witnessed falling while attempting to get out of the wheelchair. Discoloration right eye. Sent to ER. Add alarm to the wheelchair, and therapy to assess wheelchair. On 10/18/15 at 10:40 a.m.: Noted attempting to get up from the floor in the dining room. Small abrasion and laceration noted to head and right forearm. Sent to ER and returned with staples to back of head. (There was no documentation of any investigation done as to how the resident fell and/or if the fall was witnessed. There was no documentation if the helmet and alarm were intact. There was no intervention added to address the fall). On 10/21/15 at 9:45 a.m.: Noted lying on the floor beside her bed, unwitnessed. Bed in low position, keep helmet on at all times. Helmet intact. Bed down. (There is no documentation if the bed alarm was intact and/or alarming). On 11/02/15 at 7:30 a.m.: Noted lying on floor in her room behind the door, naked, wheelchair flipped over beside her. Extremely agitated. PRN given for agitation, increased visual checks. (There is no documentation as to what increased visual checks means, and for how long it is to be done. There is no documentation as to whether or not the chair alarm was intact and alarming). On 11/07/15 at 10:50 p.m.: Heard resident in room yelling, found on floor, helmet intact, complained of right wrist and hand pain. Sent to ER. diagnosed with [REDACTED]. Continue to monitor. (There is no documentation as to if the bed alarm was intact and alarming, and no investigation as to how the fall occurred). On 11/13/15 at 1:00 p.m.: Resident left unattended and fell asleep sitting on toilet, skin tears to left forearm and left eyelid. Scheduled toileting while awake, assist to restroom. Educate staff on resident safety and not leaving resident unattended on toilet. (Resident was assessed on the Quarterly MDS dated [DATE] as needing extensive assist by one staff for toilet use). On 11/27/15 at 12:00 p.m.: Resident got out of bed and fell on the floor. Alert staff to clean up spills to prevent falls and encourage resident to allow assistance with getting out of bed. Floor slippery, resident waste water. (There is no documentation if the bed alarm was intact and alarming). Review of the Daily Safety Alarm Check log noted that there was no notation if the bed alarm was functioning properly from 11/22/15-11/27/15. Review of an analysis of resident #7's falls from July 2015 to January 2016 provided by the Corporate Registered Nurse Consultant on 01/25/16 at 9:25 a.m. revealed that thirteen (13)of twenty-one (21) falls occurred on the day shift with nine occurring in the resident's room. During interview with the Corporate RN Consultant on 01/25/16 at 1:32 p.m., she stated this analysis of falls was not done until the surveyor asked if one was available on 01/22/16. Upon further interview, she stated that analysis of falls was done for all residents combined, but not done to analyze individual resident's falls. During interview with the Director of Nurses (DON) on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring of residents, but they did do hourly rounds. During further interview she stated that resident #7 moved around a lot, and staff and other residents will tell them where the resident was. During further interview with the DON regarding the individual falls for resident #7 as noted above, the DON responded as follows: 03/14/15: I don't know if the helmet was on; she snatches it off. 03/23/15: All smoke breaks are supervised, I don't know how the resident got outside. 09/23/15: The bed alarm was implemented at some time, the restorative CNA was responsible for applying it and checking the batteries. 10/21/15: I don't know if the bed alarm was on and sounding at the time of the fall; it's not on the investigation form. 11/02/15: I don't know when the seat belt was applied; it should have been recommended by the Falling Star committee. If a seat belt is used a pre-restraining assessment is done first by the nurse, and the physician contacted for an order. I just found out on 01/21/16 that she had a seat belt. I don't know if the seat belt was on when the resident was found in her room with the wheelchair flipped over next to her. 11/13/15: I don't know what the policy is, but a resident should not be left unattended in the bathroom. During further interview with the DON on 01/22/16 at 1:13 p.m., she stated she did not know why proper footwear was not on during the falls on 07/10/15, 07/20/15, 08/12/15 and 08/13/15, and assumed the fall was due to improper footwear. During further interview, she stated that she did not know if the cause of the fall on 08/13/15 was from letting go of the handrail or improperly fitting shoes, and that staff would have been asked to clarify this during the Falling Star meetings. 2. Review of resident #27's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] noted they had severe cognitive impairment, and was assessed as being totally dependent on one staff for locomotion on and off the unit. Review of their Fall Risk Evaluation dated 11/08/15 noted that they were assessed as being high risk for falls. Review of the risk for cognitive loss related to dementia, bipolar, schizophrenia and depression, as evidenced by disorganized thinking, and rambling irrelevant conversation. Review of resident #27's comprehensive falls risk care plan revealed an intervention dated 03/30/15 to add a bed alarm, and an intervention dated 06/29/15 to add a safety seat belt to the wheelchair. During observation in resident #27's room on 01/25/16 at 9:24 a.m., no bed alarm was noted on her bed. This was verified during interview with Certified Nursing Assistant (CNA) EE at this time. During observation of resident #27 in her wheelchair on 01/25/16 at 9:28 a.m., no chair alarm or seat belt was observed. This was verified during interview with Restorative CNA OO at this time, who stated that the resident had a seat belt alarm at one time, but it was changed to a regular seat belt in the wheelchair per therapy recommendation. During further interview, CNA OO stated that on Saturday, 01/23/16, she had noted the seat belt was not firmly secured to the wheelchair, and put a Maintenance request in to fix it. During further interview, she verified that no other temporary intervention was put into place while the seat belt was waiting to be repaired. During interview with Restorative CNA OO on 01/25/16 at 9:37 a.m., she verified there was no alarm on resident #27's bed, and there should have been one. Review of a Daily Safety Alarm Check form for January 2016 noted a non-functioning alarm dated 01/23/16 where one side of alarm needed to be screwed to the chair, and an intervention to report it to Maintenance as soon as possible. Further review of this Alarm Check Form revealed that a bed alarm was intact to the bed on 01/23/16 (note observation above where the alarm was not on the bed). Review of the CNA Care Plan Reference Sheet noted devices of bed alarm and seat belt alarm on at all times when the resident was out of bed. During observations of resident #27 in the wheelchair on 01/25/16 at 10:58 a.m. and 12:25 p.m.; 01/26/16 at 8:50 am. and 9:31 a.m., and 01/28/16 at 9:18 a.m., she was noted with a seat belt on. Review of her clinical record revealed that there was no assessment found for use of a seat belt, and no physician's order. During interview with the Director of Nurses on 01/26/16 at 9:26 a.m., she verified that there was no alarm on resident #27's wheelchair, stated she was unaware that there was such a thing as a seat belt alarm, and that she did not remember this as an intervention that was approved during a Falling Star meeting. Upon further interview the DON verified that no formal assessment had been done for the seat belt use. During observation and interview with the Certified Occupational Therapy Assistant (COTA) on 01/26/16 at 9:31 a.m., she demonstrated a seat belt that alarmed when opened, and verified that resident #27 did not have this type of seat belt. Upon further interview, she stated that resident #27 slid down in the chair when she pulled on the handrails in the hall, and the seat belt was to keep her from falling out of the wheelchair. Review of the care plan, Nurse's Notes and Incident/Accident Reports for resident #27's falls revealed the following: -03/16/15 at 4:30 p.m.: Found sitting on floor in front of wheelchair on A-hall. Resident condition before accident: confused and disoriented. Encourage resident not to attempt to get up without assistance. Return her to her unit after special events for monitoring. -03/30/15 at 5:30 p.m.: Fall in room. Add bed alarm. -05/29/15 at 4:30 p.m.: Fall in room, attempted to get up on own. Resident's condition before the accident: confused and disoriented. Remind resident to ask for assistance when getting out of bed. Honor wishes to not take a nap. -06/21/15 at 5:30 a.m.: Fall in resident room, heard resident calling out for help. Small abrasion to left knee. Height of bed was adjustable and down. Ensure bed in lowest position at all times. Staff to provide siderail bed mobility. -06/29/15 at 8:40 a.m.: Fall at Station 2 nurse's station. Scooted out of wheelchair. Multiple attempts had been made to throw herself to the floor. Initiate safety alarm belt as an enabler for positioning and to alert staff when attempts to throw self on floor. -08/15/15 at 3:10 p.m.: Found on floor in room after hearing a loud boom, resident said slid out of wheelchair. Resident condition before accident: confused and disoriented. Encourage to use call light for assistance with transfers. Therapy to evaluate for transfers. -09/02/15 at 2:00 p.m. Slid out of wheelchair on C-hall while self-propelling. Ensure safety belt and leg rests are properly working. Writer will discuss with other departments ways to assist resident and prevent falls. -09/08/15 at 2:30 a.m.: Fall in room on fall mat, dented mark on right forehead. Sent to ER. Encourage to ask for assistance with movement, place bedside table at foot of bed during sleep hours. -09/24/15 at 6:00 p.m.: Found leaned against wheelchair in upright position, resident stated she slid out of the wheelchair. Resident condition before accident: confused and disoriented. Encouraged resident to ask for assistance with movement. Add to Falling Star program. -11/05/15 at 1:30 p.m.: Fall in resident room, resident stated tried to get out of bed. Place safety mat at bedside. -11/05/15 at 9:00 p.m.: Slid out of chair onto floor on D-hall. Re-apply safety belt to a different wheelchair. -11/08/15 at 10:00 a.m.: Attempted to throw self out of the wheelchair several times, propelled self to room and found on floor. Physical Therapy referral for positioning. During interview with the DON on 01/27/16 at 1:02 p.m., she stated that she wrote the intervention to re-apply a safety belt to a different wheelchair after the fall on 11/06/15, as therapy had changed resident #27's wheelchair but had not applied a seat belt as per previous fall intervention. During interview with the DON on 01/27/16 at 2:10 p.m., she stated the investigation from the injury on 09/08/15 did not specify why the intervention was to place the bedside table at the foot of the bed, and that they needed to start putting information like this in the fall investigation. Review of the facility's Falling Star Program policy and procedure noted the program was intended to evaluate and determine reason(s) for falls and implement measures to prevent falls. The functions of the Falling Star committee included to review incidents of falls and develop recommendations for the care plan team; track the outcome of the plans of care in the prevention of future falls; and report findings of meetings to the QA committee. 3. Review of the Minimum Data Set(MDS) Quarterly Review dated 12/30/15 revealed Resident #26 to have a Brief Interview of Mental Status(BIMS) of nine(9) and active [DIAGNOSES REDACTED]., Anxiety, Depression, Manic Depressant, Psychotic Disorder, Schizophrenia, Repeated Falls, and Altered Mental Status(AMS). Review of the MDS Annual assessment dated [DATE] revealed The Care Area Assessment Summary (CAAS) to include Activities of Daily Living (ADL) Functional/ Rehabilitation Potential, Falls, Behavioral Symptoms, Pressure Ulcer, and Psychotropic Drug Use to be addressed in the Care-plan. Review of Section J: Falls since admit/reentry/prior assessment: any falls-yes, no injury-one, injury-one, major injury-none. The Care-plan updated on 1/17/15 revealed: Problem: Resident #26 was at risk for falls related to having a history of a pacemaker, coronary anomaly, paranoid schizophrenia, mood disorder, neuropathic pain, anxiety, extrapyramidal side effects (EPS), right below the knee amputation (BKA), psychotropic medication use and falls. Interventions included: Add anti-tippers to resident's wheelchair. Wheelchair for mobility. Assist with transfer and bed mobility. Administer medications as ordered. Therapy/restorative as indicated. Keep the call light in reach. Encourage resident to call for assistance. Keep area clean and free of clutter. Lock the wheelchair and assist resident out of bed when requested. Falls: On 12/28/15 at 12:45 p.m., resident was noted lying on the floor at bedside. Previous fall risk score: 14. On 1/6/16 at 6:50 am, resident attempted to self-transfer; no injuries. Previous Fall risk score: 16. On 1/6/16 at 7:10 p.m., resident was in hallway in wheelchair and fell on to the floor. Injury was a hematoma to the right side of his head. On 1/16/16 at 6:45 p.m., resident leaned forward and fell out of the wheelchair striking the right side of his face. Injury was a lacerations to the right side of his face. On 1/18/16 at 9:30 a.m., resident had fall without injury in the hallway when another resident pushed wheelchair. Interventions written in on the care-plan: falling star program, ER to evaluate and treat as indicated, neuro-checks as ordered, physical therapy(PT) screen/referral as needed, and again: send to emergency room for evaluation and treatment as indicated. The Falling Star Program Tracking Form dated 1/16/16 at 6:45 pm revealed Resident #26 to have had a fall with injury and the plan was to apply a wheelchair alarm. On 1/18/16 at 9:30 am, documentation revealed the resident to have had a fall without injury in the hallway; resident slid to the floor. The plan was to apply a safety belt. Fall Risk Assessments were completed for the following dates: 12/28/15, 1/6/16(2), 1/16/16, and 1/18/16 scoring 16 for the last three dates. Skin Assessment form dated 1/16/16 for fall revealed had R laceration/hematoma. Current Pertinent medications: Haldol 150 milligrams (mg) every twenty-one (21) days-schizoaffective disorder Divalproex ER 1000 mg twice a day-psychosis Lasix 20 mg twice a day-edema Seroquel 400 mg twice a day-psychosis Geodon 40 mg daily-mood disorder Geodon 80 mg at bedtime-psychosis Ativan 1 mg as needed (PRN) at bedtime-insomnia Further review of the physician's orders dated 1/16/16 revealed to send the resident to the emergency room (ER) for evaluation due to a fall with a head injury. The physician's orders dated 1/6/16 were to continue neuro-checks and physical therapy (PT) referral regarding a fall and to send to the ER for evaluation. Physician's orders for 1/7/16 were for PT to evaluate and treat as indicated. Clarification: skilled PT to see Resident #26 three(3) times per week for four(4) weeks for therapeutic exercises, neuromuscular pain, w/c training, and patient/ caregiver education. On 12/28/15, MD orders reveal to send resident to ER for evaluation of AMS/Fall and oxygen at two(2) liters per minute via nasal cannula, check oxygen saturation each shift, and conduct neuro-checks. An observation on 1/25/16 at 3:45 p.m. revealed Resident #26 back to facility in his room. The resident was in bed in a hospital gown. The bed was not in the lowest position and no side rails were observed in the up position. The call light was out of reach. The resident showed no signs of acute distress and was resting with eyes closed. An observation on 1/26/16 at 8:45 a.m. revealed resident to be in the dining room in a wheelchair at a table. The blue/purple lift/draw sheet was under the resident. No safety belt or chair alarm observed. During and interview on 1/26/16 at 9:00 a.m., the certified nursing assistance(CNA) DD, transporting resident's in and out of the dining room, confirmed that the Resident #26 did not have a chair alarm in place and no safety belt was applied to the resident's chair. The CNA notified the charge nurse and the resident was placed under close supervision. An observation on 1/27/15 in the dining room revealed Resident #26 was in his wheelchair at a table participating in an activity. The chair alarm was in place for safety precaution along with a safety belt. 4. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 0, indicating that the resident was severely cognitively impaired. Continued review revealed that the resident wandered daily and required supervision from staff for locomotion on and off the unit. Further review of the Quarterly MDS dated [DATE] revealed that staff had erroneously coded the resident as having no falls since the last prior MDS assessment. Review of the resident's care plan dated 4/29/15 revealed that the resident was at risk for falls related to excessive walking, history of falls, use of multiple psychotropic medications and removal of call light with interventions to encourage the resident to lie down when exhaustion noted, administer medications as ordered and notify the physician of any abnormal side effects, psychiatric consult and visits as ordered, staff assistance with care needs as allowed, staff to approach resident and announce why you are addressing him/her to decrease combative behavior and for the physician to review the resident's medications. Continued review revealed that the resident was at risk for injury as evidenced by wandering throughout the facility, wandering in residents rooms and taking naps in other residents' beds with interventions for staff to redirect the resident and wander monitoring per facility protocol. Review of the facility's Wandering or Missing Resident Guideline revealed that the facility would provide supervision to promote a safe environment for residents at risk for injury due to wandering behavior. Continued review revealed that if a resident repeatedly wandered off the unit, the care plan would reflect a monitoring schedule to ensure the resident's safety. Continued review revealed that residents on a monitoring schedule would be monitored either hourly or every shift or deemed necessary by the Patients at Risk (PAR) committee. Further review revealed that residents with an identified problem of wandering whose care plans did not meet the resident's needs would have a prompt review. Review of the resident's current physician's orders revealed that the resident was administered Depakote Extended Release (ER) 500 milligrams (mgs.) every

Based on observation, record review, and staff interview, the facility failed to follow the care plans for seven (7) residents ( # 7, 13, S, 25, 26, 27, and T). of thirty (30) sampled residents. On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 at CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S): K). this information was repeated with the Corporate Nurse Consultant on 01/19/16 at 2:55 p.m. It was determined that the noncompliance with one or more requirements of participation caused, is likely to cause, serious injury, harm, impairment or death to residents. The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/2015 and a fracture to the nose on 1/14/2016; to Resident S who sustained a [MEDICAL CONDITION] on 6/9/2015 and a shoulder fracture on 11/10/2015; to Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. In addtion actual harm occurred to Resident #25 and Resident S who developed pressure sores in the facility due to failure to assess and apply pressure relief interventions. A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S: K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to in-service staff on monitoring of these rooms. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S: K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S: J), CFR 483.20 Resident Assessment (F 282 S/S: K), CFR 483.30 Nursing Services (F 353 S/S: K), and CFR 483.75 Administration (F 490 S/S: K), and CFR 483.75(o)(1) Qaa (F520 S/S:K). 1. Review of Resident T's care plan dated 3/7/15 and last reviewed 12/29/15 revealed that the resident was at risk for falls related to decreased mobility, [MEDICAL CONDITION] and use of psychiatric medications with an intervention for staff to have his/her call light within reach and to keep the bed in the lowest position at all times. On 1/22/16 at 3:32 p.m. and on 1/25/16 at 10:10 a.m., 12:15 p.m. and 5:20 p.m., Resident T was lying in his/her bed. The bed was not in its lowest position. On 1/25/16 at 5:30 p.m. the top of the mattress measured twenty-eight (28) inches from the floor. On 1/26/16 at 8:00 a.m., the resident was lying in the bed and the bed was not in its lowest position. Certified Nursing Assistant (CNA) LL confirmed at that time that the bed was not in its lowest position and used the crank at the end of the bed to lower the bed. On 1/26/16 at 8:05 a.m., the resident's call light was observed lying in his/her wheelchair out of reach of the the resident. Interview with Resident T at that time revealed that he/she could use the call light and that it was for emergencies. On 1/26/16 at 4:15 p.m., the resident was sitting in his/her wheelchair in the room. However, his/her call light was on the floor behind the wheelchair out of the resident's reach. On 1/27/16 at 1:15 p.m. and 3:30 p.m., the resident was in the bed and the bed was not in its lowest position. On 1/27/16 at 1:15 p.m., the resident demonstrated that he was able to use the call light to call for assistance. On 1/29/16 at 8:55 a.m., the resident's bed was assessed with [REDACTED]. Cross reference to F323. 2. Review of Resident #25's care plan dated 4/11/15 and reviewed 7/21/15 and 10/6/15 revealed that the resident was at risk for skin breakdown related to decreased mobility, history of pressure sores, diabetes, venous stasis disease, refusal to be turned and repositioned and incontinence of bowel and bladder. Interventions included certified nursing staff to observe the resident's skin during showers and activities of daily living (ADL) care for early signs of breakdown and to notify the charge nurse and for the charge nurse to conduct skin assessments per facility protocol. review of the resident's medical record revealed [REDACTED]. However, there was no indication that certified nursing staff had consistently assessed the resident's skin during showers or baths as care planned except for assessments on 7/16/15 and 7/17/15. Furthermore there was no indication that licensed nursing staff had assessed the resident's skin weekly per facility protocol as care planned. Interview with the LPN Treatment Nurse on 1/28/16 at 10:50 a.m. revealed that she was unable to locate any of the weekly skin assessments that licensed nursing staff were supposed to perform on the resident prior to the identification of the DTI on 7/26/15. Continued interview with the LPN Treatment Nurse revealed that she was responsible for ensuring that the CNAs and the nurses completed the skin assessments. Cross reference to F314. 3. Review of Resident S's care plan dated 2/16/15 and reviewed 5/19/15 and 6/15/15 revealed that he/she had the potential for skin breakdown related to limited mobility with interventions for certified nursing staff to observe the resident's skin during showers/ADL care for early signs of skin breakdown and notify the charge nurse and for licensed nursing staff to perform skin assessments per facility protocol. review of the resident's medical record revealed [REDACTED]. However, there was no indication that certified nursing staff had consistently assessed the resident's skin during showers or baths as care planned prior to the identification of the DTI except on 7/7/15. Furthermore there was no indication that licensed nursing staff had assessed the resident's skin weekly per facility protocol as care planned. Interview with LPN Treatment Nurse on 1/22/16 at 11:25 a.m. revealed that she had reviewed the Licensed Nurse Skin Assessment Book and could not find any weekly skin assessments performed by licensed nursing staff prior to the identification of the DTI on the resident's heel on 7/14/15. Further interview revealed that she obtained the CNA Skin Assessment Checklist Forms and the Weekly Skin Assessment Forms completed by licensed nursing staff at the end of each week and kept the forms in a notebook in the copy room. Further interview revealed that she was responsible for ensuring that the nurses were completing the weekly skin assessments. Cross reference F314. 4. Review of resident #27's comprehensive falls risk care plan included an intervention dated 03/30/15 to add a bed alarm, and an intervention dated 06/29/15 to add a safety seat belt to the wheelchair. During observation in resident #27's room on 01/25/16 at 9:24 a.m., no bed alarm was noted on her bed. This was verified during interview with Certified Nursing Assistant (CNA) EE at this time. During observation of resident #27 in her wheelchair on 01/25/16 at 9:28 a.m., no chair alarm or seat belt was observed. This was verified during interview with Restorative CNA OO at this time. 5. Review of resident #7's comprehensive falls risk care plan with a Problem Onset date of 10/03/14 revealed the following interventions, and review of Incident/Accident Reports and Falling Star Forms revealed that the interventions were not being followed as follows: a. Apply safety helmet, and staff to assist resident with putting helmet on when resident isn't wearing helmet. -03/14/15: Resident was brought out of the dining room due to agitated behavior, and dropped to the floor and began banging her head on the floor causing a gash in the top of her head. Additional comments were to make sure resident has helmet on at all times. -08/13/15: Resident walking up B-hall, let go of railing and fell to floor receiving an abrasion to back of her head. Comment included to ensure wearing helmet. -10/21/15: Noted lying on floor bedside bed, complained of right ear pain. Additional comments included to keep helmet on at all times. b. Assist resident during smoke breaks. -Review of a Falling Star Program Tracking Form noted that on 03/23/15 at 9:15 a.m., the resident stated that she had a fall twice while outside in the smoking area and scraped her left hip. The Plan included for staff to assist her to and from the smoking area due to unsteady gait and non-compliance with wearing helmet. c. Ensure that resident has and wears properly-fitting non-skid soled shoes for ambulation. -07/10/15: Resident was witnessed walking in the hallway and she tirpped and fell and hit the right side of her head on the floor. Additional comments noted to ensure resident is wearing proper footwear. -07/20/15: Resident walking around in another resident's room and tripped over her foot, shoes not tied. Additional comments noted that shoe laces were put into resident's shoes. -08/13/15: Resident walking up B-hall, let go of railing and fell to floor receiving an abrasion to back of her head. Comment included to ensure proper fitting shoes. d. Analyze previous falls by resident to determine whether pattern/trend can be addressed. -During interview with the Corporate Registered Nurse Consultant on 01/25/16 at 1:32 p.m., she stated that the analysis for falls for resident #7 to analyze the number of falls per time of day and location was not done until the surveyor asked for it on 01/22/16, and that they otherwise only analyzed falls for all residents combined. Cross-refer to F 323. Review of resident #7's risk for skin breakdown care plan with a Problem Onset date of 01/13/16 noted interventions for a cushion to the chair, and nurses to perform weekly skin assessments. a. During observations of resident #7 in her wheelchair, no pressure-reduction pad was noted in the seat on 01/19/16 at 4:50 p.m.; 01/20/16 at 7:45 a.m.; 01/21/16 at 12:41 p.m. and 2:24 p.m.; 01/22/16 at 10:49 a.m.; and 01/25/16 at 9:18 a.m. This was verified during interview with CNA EE on 01/21/16 at 11:22 a.m. b. Review of Weekly Pressure Ulcer Records noted the resident developed two Stage II pressure ulcers on 11/18/15, one on each trochanter area over the bony prominences. Review of Skin Assessment Forms completed by licensed nurses revealed no skin breakdown on 10/02/15; 10/10/15; 10/22/15; and 10/29/15. Review of the next Skin Assessment Form done by a licensed nurse was dated 11/18/15, the day the pressure ulcers were identified. This was verified during interview with the Licensed Practical Nurse (LPN) Treatment Nurse on 01/20/16 at 12:46 p.m. Cross-refer to F 314. Review of resident #7's comprehensive falls risk care plan with a Problem Onset date of 01/13/16 included interventions to alert staff to resident's wandering behavior, and that if the resident was wandering away from the unit, instruct staff to stay with resident, converse and gently persuade resident to walk back to designated area with them. During continuous observations on 01/21/16 from 2:24 p.m. to 4:02 p.m., resident #7 was noted to exhibit agitated behaviors as evidenced by cursing, yelling, crying, and self- propelling her wheelchair on the B-hall and C-halls, including into seven resident rooms, and the dining room. At 3:45 p.m. the resident was observed to self-propel her wheelchair from the B-hall through the dining room and solarium, to the A-hall, without staff intervention. Upon further observation she rolled herself into room A-5, where she remained until 4:02 p.m. when a family member of a resident in that room alerted the staff. Cross-refer to F 224. Review of resident #7's comprehensive behaviors care plan dated 10/03/14 and 01/13/16 noted an intervention for a psych consult as needed. -Review of her Medication Administration Records revealed that besides her routine [MEDICAL CONDITION] meds, the resident received as-needed (prn) doses of an antianxiety drug seventeen times, and an antipsychotic drug twenty times in November; a prn antianxiety drug ten times and an antipsychotic drug sixteen times in December; and a prn antianxiety drug four times and antipsychotic drug eight times in January for agitation. Review of Nurse's Notes dated 01/27/16 at 8:15 a.m. noted the resident was extremely agitated including physical and verbal aggression, During interview with LPN CC on 01/28/16 at 12:22 p.m., she stated that resident #7 had to be sent to the senior behavioral heath hospital on [DATE] due to continuing agitated and aggressive behaviors. Review of the psychiatrist's progress notes revealed that the last time that there was documentation that she was asked to see the resident was on 09/02/15. This was verified during interview with the Social Services Director on 01/29/16 at 9:24 a.m. Cross-refer to F 250. Findings included: 6. Review of the Minimum Data Set (MDS) Quarterly Review dated 12/30/15 revealed Resident #26 to have a Brief Interview of Mental Status (BIMS) of nine (9) and active [DIAGNOSES REDACTED]., Anxiety, Depression, Manic Depressant, [MEDICAL CONDITIONS], Repeated Falls, and Altered Mental Status (AMS). Review of the MDS Annual assessment dated [DATE] revealed The Care Area Assessment Summary (CAAS) to include Activities of Daily Living (ADL) Functional/ Rehabilitation Potential, Falls, Behavioral Symptoms, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use to be addressed in the Care-plan. Review of Section J: Falls since admit/reentry/prior assessment: any falls-yes, no injury-one, injury-one, major injury-none. Review of the Care-plan updated on 1/17/15 revealed: Problem: Resident #26 was at risk for falls related to having a history of a pacemaker, coronary anomaly, paranoid [MEDICAL CONDITION], mood disorder, neuropathic pain, anxiety, extrapyrimidal side effects (EPS), right [MEDICAL CONDITION] (BKA), [MEDICAL CONDITION] medication use and falls. Interventions included: Add anti-tippers to resident's wheelchair. Wheelchair for mobility. Assist with transfer and bed mobility. Administer medications as ordered. Therapy/restorative as indicated. Keep the call light in reach. Encourage resident to call for assistance. Keep area clean and free of clutter. Lock the wheelchair and assist resident out of bed when requested. Review of the Falling Star Program Tracking Form dated 1/16/16 at 6:45 pm revealed Resident #26 to have had a fall with injury and the plan was to apply a wheelchair alarm. On 1/18/16 at 9:30 am, documentation revealed the resident to have had a fall without injury in the hallway; resident slid to the floor. The plan was to apply a safety belt. Review of the physician's orders [REDACTED]. Current Pertinent medications: [REDACTED] [MEDICATION NAME] 150 milligrams(mg) every twenty-one(21) days-[MEDICAL CONDITION] disorder [MEDICATION NAME] ER 1000 mg twice a day-[MEDICAL CONDITION] [MEDICATION NAME] 20 mg twice a day-[MEDICAL CONDITION] [MEDICATION NAME] 400 mg twice a day-[MEDICAL CONDITION] [MEDICATION NAME] 40 mg daily-mood disorder [MEDICATION NAME] 80 mg at bedtime-[MEDICAL CONDITION] [MEDICATION NAME] 1 mg as needed(PRN) at bedtime-[MEDICAL CONDITION] Further review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Clarification: skilled PT to see Resident #26 three (3) times per week for four (4) weeks for therapeutic exercises, neuromuscular pain, wheelchair training, and patient/caregiver education. On 12/28/15, MD orders reveal to send resident to ER for evaluation of AMS/Fall and oxygen at two (2) liters per minute via nasal cannula, check oxygen saturation each shift, and conduct neuro-checks. An observation on 1/25/16 at 3:45 p.m. revealed Resident #26 back to facility in his room. The resident was in bed in a hospital gown. The bed was not in the lowest position and no side rails were observed in the up position. The call light was out of reach. The resident showed no signs of acute distress and was resting with eyes closed. An observation on 1/26/16 at 8:45 a.m. revealed Resident #26 to be in the dining room in a wheelchair at a table. The blue/purple lift/draw sheet was under the resident . No safety belt or chair alarm observed. During an interview on 1/26/16 at 9:00 a.m., the certified nursing assistance (CNA) DD, transporting resident's in and out of the dining room, confirmed that the Resident #26 did not have a chair alarm in place and no safety belt was applied to the resident's chair. CNA DD notified the charge nurse and the resident was placed under close supervision. An observation on 1/27/15 in the dining room revealed Resident #26 was in his wheelchair at a table participating in an activity. The chair alarm was in place for safety precaution along with a safety belt. 7. A review of resident # 13 ' s medical record and Minimum Data Set (MDS) reveals [DIAGNOSES REDACTED]. The resident ' s Brief Interview for Mental Status (BIMS) score is 8. MDS reveals the resident has disorganized thinking and hallucinations, requires 1 person physical assist with transfers, walking in room, and locomotion on and off of the unit. The medical record reveals the resident had falls on 7/21/2015, 9/3/2015, 9/18/2015, 10/29/2015, and 12/7/2015. A review of the care plan initiated 6/3/2015 revealed an undated intervention for the resident to call for assistance, ensure the resident ambulates with nonskid socks, and ambulates with assistance. An observation of resident 13 on1/26/2016 at 12:1 0 p.m., reveals the resident lying in bed with regular socks on her feet. The resident states she goes to the bathroom by herself by holding on to objects. States she has had falls, but doesn ' t know why. On 1/26/2016 an interview was conducted with CNA HH at 2:20 p.m. HH reveals she assists the resident with her bath and dressing. She states the resident uses the socks in her drawer, but they are not non-skid socks. HH confirms that the resident ambulates to the bathroom without assistance. On 1/27/2016 at 8:30 a.m., resident # 13 was observed standing in the doorway of her room closing the door. The resident was observed to have on socks that did not have non-skid soles. On 1/28/2015 at 1:50 p.m., the resident was observed in bed and was wearing socks that did not have non-skid soles. An interview was conducted with LPN GGwho told surveyor that she did not know if the resident was supposed to have on non-skid socks or not. An observation completed on 1/29/2016 at 11:50 a.m. reveals the resident is lying in bed and wearing regular socks. The soles are not non-skid. The resident was agitated and requested the surveyor leave. No further observations were made.

Based on observation, clinical record review, facility policy and procedure review, and staff interview, the facility failed to ensure a cognitively impaired resident (#7) was free from neglect by not providing supervision necessary to ensure her safety, as well as to protect other residents in the facility from her potentially aggressive behaviors. The facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents. There was documentation in the Nurse's Notes and Falling Star notes on 03/24/15 that the resident fell outside in the smoking area sustaining an abrasion to the left hip, with no documentation that staff were supervising her. In addition, the resident was involved in nine (9) resident-to-resident altercations from 04/12/15 to 01/21/16, resulting in injuries including a [MEDICAL CONDITION] and black eye for resident #7, and scratches for resident #23 and an unsampled resident. The noncompliance caused actual harm to R#2, who sustained a laceration to the chin on 11/29/2015, a fracture to the nose on 1/14/2016; resident S who sustained a [MEDICAL CONDITION] on 6/9/2015, a shoulder fracture on 11/10/2015, and; to R#7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S: K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S: J), CFR 483.20 Resident Assessment (F 282 S/S: K), CFR 483.30 Nursing Services (F 353 S/S: K), and CFR 483.75 Administration (F 490 S/S: K), and CFR 483.75(o)(1) Qaa (F520 S/S:K). Immediate Jeopardy (IJ) was identified on 01/26/16, and the facility Administrator and Corporate Nurse Consultant were notified at 2:01 p.m. IJ was determined to exist as of 03/14/15 related to non-compliance at CFR 483.25 (F 323 S/S-K), and CFR 483.13 Resident Behavior/Facility Practices (F 224 S/S-J). The IJ also determined that the provider ' s non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The IJ was determined to be ongoing. Findings include: Review of resident #7's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a History and Physical (H&P) from a geriatric behavioral health facility dated 10/13/14 noted the resident was referred to them after having combative behavior and violent outburst episodes. Continued review of this H&P revealed the resident had also been admitted to this psych facility on 08/02/10 for aggressive behavior, and had several admissions for the same behavior at that facility as well as other hospitals in Georgia. Review of an H&P from the geriatric behavioral health facility dated 08/18/15 revealed the resident was admitted there due to increased agitation and combative behavior, including physically striking and scratching other residents and staff, and was not able to be redirected. Further review of this H&P revealed that despite receiving a prn (as needed) drug, she was shrieking and screaming at the top of her lungs and was uncontrollable. Review of the Reason for hospitalization section of the form included that she was a potential danger to herself and others. Review of the History of Present Illness from this psych admission revealed that she was increasingly manic and highly delusional; had been throwing things such as chairs on other residents; extremely erratic and very dangerous. Review of resident #7's behavior care plan with a Problem Onset date of 01/13/16 revealed that she had socially inappropriate behavior as evidenced by yelling, cries out loud, screams, sexually inappropriate statements to staff, visitors, and residents, uses profanity, and altercations with residents at times. Review of the interventions for this care plan included to place her in an area where constant observation was possible; remove from public area when her behavior was disruptive or unacceptable. Review of resident #7's risk for injury care plan revealed interventions including to place the resident in a location where constant observation was possible and to not leave unattended; if resident wandering away from unit instruct staff to stay with her and persuade her back to designated area with them. Review of the risk for falls care plan revealed interventions to increase rounds to prevent risk of unwitnessed falls and injury, and to place resident in area where constant observation was possible. Review of Incident/Accident Reports, Falling Star notes, and Nurse's Notes revealed the following resident-to-resident incidents, or unwitnessed falls when out of her room: On 03/20/15 at 10:30 p.m.: The resident was noted with a skin tear to the left hip. On 03/23/15 at 9:15 a.m., the resident stated she fell while out in the smoking area. On 04/12/15 at 6:05 a.m.: The resident was noted in the dining room attempting to hit another resident, lost her balance and fell backward hitting the back of her head on the floor and causing lacerations to the back of her head. On 08/12/15 at 8:30 a.m.: Another resident reported that resident #7 fell in the lobby on Station 2. Resident noted to have abrasions to left side of face and forehead. On 08/14/15 at 9:40 a.m.: Resident combative, went into dining room and began hitting another resident, attacking staff and other residents on the C-hall, including resident #23. When resident #23 attempted to move out of the way he fell , no injuries noted. On 08/17/15 at 12:30 p.m.: Reported by another (unsampled) resident that resident #7 scratched his right lower arm for no reason. Resident #7 noted to be agitated. The (unsampled) resident was noted to have at least fifteen small to medium superficial scratches to his right lower arm. On 09/01/15 AT 5:00 p.m.: Per review of the Accident/Incident Monthly Tracking Log, there was a resident to resident altercation in the dining room involving resident #7. However, during interview with the interim Director of Nurses (DON) on 01/27/16 at 1:30 p.m., she could not find the Incident Report, and Medical Records staff could not locate Nurse's Notes for that date, so details of the incident are unknown. On 09/06/15 at 11:30 a.m.: Resident #7 was pushed to the floor in the dining room by another (unspecified) resident, who stated he pushed her when resident #7 hit him. On 09/07/15 at 12:00 p.m.: Resident #7 was agitated, went into the dining room during lunch, pinched another resident and threw the lunch tray across the table. On 10/18/15 at 10:40 a.m.: Writer called to the dining room by another nurse, resident noted attempting to get up from the floor (no documentation if the fall was witnessed). Sent to ER, three staples to back of head. On 10/27/15 at 3:54 a.m.: Resident #7 was hit in the eye by another (unsampled) resident causing a bruise. The other resident was angry at resident #7 for something she said. On 11/13/15 at 1:00 p.m.: Resident fell off the commode when left unattended and sustained a skin tear to her left forearm and left eyelid. On 01/21/16 at 12:20 p.m.: Resident #7 pulled another resident's hair during breakfast and was removed from the dining room and redirected to hall, extremely agitated. Threw a cup of water at the writer at the nurse's station. At 11:45 a.m. the resident went into the dining room and hit another resident on the back of the head. During interview with Certified Nursing Assistant (CNA) EE on 01/21/16 at 10:45 a.m., she stated that it was not unusual for resident #7 to be agitated. During interview with CNA OO on 01/21/16 at 12:25 p.m., she stated that she had known resident #7 to hit other residents about three times, and that she will curse at them. During interview with Licensed Practical Nurse (LPN) KK on 01/21/16 at 12:30 p.m., she stated that resident #7 got agitated often and would hit other residents and they checked on her often, but that they could not isolate her. During interview with the Activity Director on 01/28/16 at 11:21 a.m., she stated that resident #7 had a very short attention span, and was disruptive and would yell, scream and curse at times. Upon further interview, she stated that the resident had hit her and other residents before. During interview with LPN CC on 01/28/16 at 12:22 p.m., she stated that resident #7 had to be sent to the geriatric behavioral health facility on 01/27/16, as she was threatening to kill staff and tried to kick a contractor working on the nurse call system off his ladder. During continuous observation on 01/21/16 beginning at 2:24 p.m., resident #7 was noted to curse, yell, and self-propel her wheelchair out of her room and down the C-hall. Further observation revealed that she passed three staff, none of whom tried to redirect her to her room. At 2:35 p.m., CNA WW was observed to redirect the resident back to her room after the resident reached the end of C-hall. During interview with CNA WW at this time, she stated that if resident #7 was agitated they tried to keep her in her room. At 2:37 p.m., resident #7 was observed to wheel herself out of her room and entered rooms C-9, B-2, B-6 while yelling and cursing, and was brought out of these rooms by staff. During further observation she was noted to wheel herself on the B- and C-halls, and then entered room C-3 at 2:48 p.m. at which time the resident in that room asked staff to remove her. During further observation the resident rolled herself into room C-7 at 2:52 p.m. During observation at 3:03 p.m., the resident was noted to wheel herself down the B-hall to the dining room, and a CNA passed her without attempting to redirect her. During observation at 3:07 p.m., the resident entered room B-7 where she stayed unsupervised for two minutes, before wheeling herself down to the Station 2 nurse's station. During further observation at 3:15 p.m., the resident wheeled herself to the dining room and stopped at the first table where two residents were sitting, and told them I hate you, and was crying out. During continued observation three staff were noted to walk past her as she was going down the B-hall, but they did not redirect her. After staff provided her a sandwich in the dining room at 3:22 p.m., the resident was observed to wheel herself into room B-12 at 3:40 p.m. at which time staff brought her to the Station 2 nurse's station. During observation at 3:45 p.m., the resident wheeled herself down the B-hall through the dining room and solarium, then down the A-hall and into A-5's bathroom, where she remained until 4:02 p.m., at which time a family member of a resident in room A-5 alerted staff. During interview with the interim DON on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring, and that staff and other residents would tell them where the resident was. During further interview, she stated that it was acceptable for resident #7 to wheel herself around the facility by herself as long as she was not agitated. During further interview, she stated that staff should try to redirect the resident close to the nurse's station or her room if she was agitated, as they did not want her to harm anyone else. Review of the facility's Abuse or Exploitation of Residents Policy and Procedure revealed that Neglect referred to failing to provide goods and services necessary to avoid physical harm. Review of the Resident to Resident Abuse section of the policy noted that the facility's goal was to provide a safe and loving environment to meet the needs of all that they served.

Based on observation and record review, it was determined that the facility failed to revise the care plan to include interventions for staff to ensure that a resident was wearing non-skid socks at all times and were monitoring the resident's whereabouts per a specific monitoring schedule for one (1) resident (#2); failed to revise the care plan to include interventions to maintain the bed in the lowest position and ensure that the door to the resident's room remained open for one(1) resident (S); and failed to revise the care plan related to the use of bed and chair alarms for one (1) resident (#7). Nine (9) residents were reviewed for falls from a sample of thirty (30) residents. The facility did not revise the residents Falls care plans to decrease the likelihood of future falls. The facility's failure to update the Falls care plans resulted in Immediate Jeopardy (IJ) as evidenced by a chin laceration on 11/29/15 and a nose fracture on 1/14/16 for Resident #2; a [MEDICAL CONDITION] on 6/9/15 and a shoulder fracture on 11/10/15 for Resident S; and a [MEDICAL CONDITION] on 10/18/15 and an arm fracture on 11/07/15 for Resident #7. Immediate Jeopardy (IJ) was identified on 1/26/15 and the facility Administrator and Corporate Nurse Consultant were notified on 1/26/15 at 2:01 p.m. IJ was determined to exist as of 3/14/15 and remains ongoing. It was also determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The IJ was related to non-compliance with Resident Assessment (F280 S/S J) for Resident #2, Resident S, Resident #7. Cross reference to Quality of Care F323. The findings include: 1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 0, indicating that the resident was severely cognitively impaired. Continued review revealed that the resident wandered daily and required supervision from staff for locomotion on and off the unit. Review of the resident's care plan dated 4/29/15 revealed that the resident was at risk for falls related to excessive walking, history of falls, use of multiple [MEDICAL CONDITION] medications and removal of call light with interventions to encourage the resident to lie down when exhaustion noted, administer medications as ordered and notify the physician of any abnormal side effects, psychiatric consult and visits as ordered, staff assistance with care needs as allowed, staff to approach resident and announce why you are addressing him/her to decrease combative behavior and for the physician to review the resident's medications. Continued review revealed that the resident was at risk for injury as evidenced by wandering throughout the facility, wandering in residents rooms and taking naps in other residents' beds with interventions for staff to redirect the resident and wander monitoring per facility protocol. Review of the facility's Wandering or Missing Resident Guideline revealed that the facility would provide supervision to promote a safe environment for residents at risk for injury due to wandering behavior. Continued review revealed that if a resident repeatedly wandered off the unit, the care plan would reflect a monitoring schedule to ensure the resident's safety. Continued review revealed that residents on a monitoring schedule would be monitored either hourly or every shift or as deemed necessary by the Patients at Risk (PAR) committee. Further review revealed that residents with an identified problem of wandering whose care plans did not meet the resident's needs would have a prompt review. review of the resident's medical record revealed [REDACTED]. Continued review revealed that the resident was hospitalized in 6/2015 for physically aggressive behaviors and his/her [MEDICAL CONDITION] medications were adjusted at that time. Review of the facility's Incident/Accident Reports revealed that the resident had ten (10) falls between 8/30/15 and 1/19/16. Review of the Incident/Accident Reports for 8/30/15, 9/21/15 at 9:00 a.m., 9/21/15 at 2:30 p.m., 10/30/15, 11/14/15, 11/29/15 and 1/19/16 revealed that the resident was out of his/her room while ambulating. Review of the Incident/Accident Report dated 11/29/15 at 8:20 p.m., revealed that the resident jumped up out of the bed and began walking very fast in the hallway with an unsteady gait. The resident fell facedown and sustained a two (2) inch laceration under his/her chin that required a visit to the Emergency Department and sutures. Review of the Falls Report Investigation dated 11/29/15 revealed that the resident was not wearing shoes or non-skid socks at the time of the fall. Review of the Falling Star Program Tracking Form dated 11/30/15 revealed that staff were supposed to ensure that the resident had on non-skid socks and/or appropriate shoes. Review of the facility's Incident/Accident Report dated 1/14/16 at 8:05 p.m., revealed that the resident was observed lying in his/her roommate's bed and staff documented that the resident had fallen in the room while ambulating. The resident was sent to the Emergency department and assessed with [REDACTED]. Review of the Falls Report Investigation dated 1/14/16 revealed that the resident was wearing inappropriate footwear at the time of the fall. Review of the Falling Star Program Tracking Form dated 1/15/16 revealed that staff were supposed to ensure that the resident had on non-skid socks or shoes when out of bed. Review of the resident's care plan revealed new interventions for staff to place the resident on the Falling Stars Program, provide treatments as ordered, obtain Therapy screen/consult, redirect the resident after meals to his/her own room and assist the resident with putting on shoes when up. However, none of the new interventions were dated. Obseervation on 1/20/16 at 7:55 a.m., Resident #2 was sitting on the side of his/her bed eating breakfast. The resident was wearing regular socks at that time. On 1/21/16 at 7:20 a.m. and 12:30 p.m. and on 1/22/16 at 8:00 a.m., the resident was in the bed wearing regular socks. Interview with Licensed Practical Nurse (LPN) KK on 1/21/16 at 2:12 p.m. revealed that the resident wandered/paced all over the facility at will and that his/her gait was unsteady depending on how much sleep she/he had the previous night. Continued interview with KK revealed that she/he monitored the resident's room and hall for clutter and ensured that the resident's shoelaces were tied. Further interview revealed that staff attempted to redirect the resident to his/her room to lie down but, the resident would not stay there. Interview with Certified Nursing Assistant (CNA) LL on 1/21/16 at 2:25 p.m. revealed that staff monitored the resident for falls and that she/he encouraged the resident to sit and rest. Continued interview revealed that the resident would walk to other halls but, she/he did not follow the resident to the other halls. Further interview with LL revealed that she/he was unable to verbalize other interventions in place to prevent further falls for the resident. Interview with the Director of Nursing (DON) on 1/22/16 at 1:30 p.m. revealed that staff had not determined the root cause of the resident's falls since 8/30/15 and that the resident's falls had occurred on different shifts. Continued interview revealed that she expected licensed nursing staff to notify certified nursing staff to monitor a resident more frequently if that resident had received a medication that caused potential sedation/drowsiness. Further interview revealed that she did not expect staff to follow the resident to other parts of the facility to monitor because the resident did not pose harm to other residents. Interview with CNA II on 1/26/16 at 1:05 pm revealed that licensed nursing staff would tell her/him to watch the resident after the nurse had administered his/her antianxiety medication. Continued interview revealed that the resident was supposed to be monitored every 15 minutes. Further interview revealed that she/he may be in another resident's room and Resident #2 will just get out of bed and start walking. Continued interview revealed that she/he would not be able to monitor the resident when providing care for another resident. Review of the facility's Falling Star Program Policy revealed that the purpose of the program was to identify a resident at risk for falls, to increase staff awareness of each resident's safety needs in order to protect the resident, to evaluate and determine reason (s) for falls and to implement measures to prevent falls. Further review revealed that the Falling Star Committee would be composed of the following team members: Director of Nursing (DON), Minimum Data Set/Care Plan Coordinator, Medical Records Coordinator, Restorative Nurse, Rehabilitation (Restorative) Aide, Maintenance Director and one Certified Nursing Assistant (CNA). The functions of the committee were to review incidents of falls and develop recommendations for the Care Plan Team, track the outcome of the plans of care in the prevention of future falls and to determine the educational needs of staff. Further review revealed that the MDS/Care Plan Coordinator was responsible for updating the Falling Stars list in the Activities of Daily Living (ADL) book and to ensure that the care plans of residents on the Falling Star program addressed falls and other related problems. Continued review revealed that Certified Nursing Staff and Licensed Nursing Staff were supposed to monitor the whereabouts and condition of all Falling Stars at regular intervals not to exceed two (2) hours. Although staff had identified Resident #2 as being at risk for injury due to wandering throughout the facility, staff failed to revise the resident's care plan to include an effective monitoring schedule to ensure the resident's safety. Although the Falling Stars committee had identified that the resident was not wearing appropriate footwear when he/she fell on [DATE] and 1/14/16 and sustained injuries at those times, there was no indication that staff had identified and revised the resident's care plan to include an intervention to address the resident's wandering at will and potential need to wear non-skid footwear at all times to prevent future falls. 2. Resident S was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was alert and oriented, was ambulatory with set-up assistance only from staff, was continent of bladder and bowel and independent with toileting, and was independent with transfer with set-up assistance only from staff. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating that the resident was alert and oriented, was non-ambulatory, was always incontinent of bladder and bowel and required total assistance from one staff person for transfer and toileting. Review of the resident's care plan dated 2/16/15 revealed that the resident was at risk for falls related to medication usage, [MEDICAL CONDITION] in his/her left eye, hypertension, [MEDICAL CONDITION], dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder with interventions for staff to keep the room and common areas free of clutter, to keep the call light within reach, to encourage the resident to call for assistance, to provide therapy services to make functional gains in Activities of Daily Living (ADL) functioning and to provide adaptive equipment as needed. Review of the Incident/Accident Report dated 6/9/15 revealed that the resident had a fall in his/her room with the door closed. The resident sustained [REDACTED]. Continued review of the Incident/Accident Report dated 11/10/15 revealed that the resident's bed was in the up position at the time of the fall. The resident sustained [REDACTED]. Review of the resident's care plan revealed that staff revised the care plan to include new interventions for therapy to screen upon return from the hospital, to place the resident on the Falling Star Program and to apply a sling on the resident's right arm. Observation on 1/19/16 at 4:44 p.m., Resident S was lying in bed. Observation of the bed revealed that staff had failed to lower the bed to its lowest position. The top of the mattress was observed approximately 3 feet from the floor. On 1/20/16 at 8:15 a.m., the resident was in the bed but, the bed was not in its lowest position. Observation on 1/21/16 at 2:29 p.m., the resident was in his/ her wheelchair in his/her room reading with the door closed. Continued observation of the resident's closed door revealed that at 2:40 p.m., Certified Nursing Assistant (CNA) NN knocked on the resident's door and entered the resident's room. NN came out of the resident's room at 2:41 p.m. pulling the door almost closed behind him/her. Continued observation of the resident's door revealed that it remained closed until 4:00 p.m. Observation of the resident at that time revealed the resident in his/her wheelchair in the room. Resident S stated at that time that he/she preferred the door open but, his/ her roommate wanted it closed. On 1/25/16 at 4:30 p.m. and on 1/26/16 at 8:15 a.m. and 9:48 a.m., the resident was in the bed but, the bed was not in the lowest position. On 1/26/16 at 9:48 a.m., CNA DD used the crank at the end of the resident's bed to lower the bed to the lowest position. Interview with DD at that time revealed that she/he did not know why the bed had been raised but, that it should have been in its lowest position. Although staff had identified that the resident's fall on 6/9/15 was in his/her room with the door closed, staff failed to revise the resident's care plan after the 6/9/15 fall to include an intervention to keep the resident's door open for more effective monitoring. Although staff had identified that the resident's bed was in the up position when he/she fell on [DATE] while transferring from the wheelchair to the bed, staff failed to revise the resident's care plan after the 11/10/15 fall to include an intervention for staff to maintain the resident's bed in the lowest position to prevent further falls. 3. Review of a Falling Star Tracking Form dated 09/23/15 at 12:15 a.m. noted that resident #7 was witnessed throwing herself on the floor, with a plan to add a bed alarm so staff would know when the resident got out of bed. Review of a Falling Star Tracking Form dated 10/07/15 at 3:25 p.m. noted the resident was found on the floor by her wheelchair, with a plan to add alarm to the wheelchair. Review of the comprehensive risk for falls care plan with a Problem Onset of 10/03/14 noted an undated, handwritten intervention for adding a bed and chair alarm. Review of the risk for falls care plan with a Problem Onset date of 01/13/16 did not contain interventions for a bed or chair alarm. During observations in resident #7's room on 01/20/16 at 1:45 p.m.; 1/21/16 at 6:43 a.m., 9:18 a.m. and 11:15 a.m.; no bed alarm was seen. During interview with CNA EE on 01/21/16 at 11:22 a.m., she stated that resident #7 did not have a bed alarm, and that they kept her in a place where they could monitor her and keep her occupied. During observation of the resident in the wheelchair on 01/22/16 at 10:30 a.m., a chair alarm was noted on the back of the wheelchair, but it was not clipped to her clothing, and there was no seat belt. This was verified during interview with CNA JJ on 01/22/16 at 10:49 a.m., who stated the chair alarm was discontinued when the seat belt was applied. During observation on 01/25/16 at 9:18 a.m., a chair alarm was noted on the back of resident #7's wheelchair, but it was not clipped to her clothing. Review of Incident/Accident Reports noted falls from the wheelchair with no documentation of the presence of a chair alarm after this was added as an intervention: On 10/18/15 at 10:40 a.m. (sustained a laceration to the back of her head); and 11/02/15 at 7:30 a.m. Review of Incident/Accident Reports noted falls from the bed with no documentation of the presence of a bed alarm after this was added as an intervention: on 10/21/15 at 9:45 a.m.; on 11/07/15 at 10:50 p.m. (sustained an arm fracture); and on 11/27/15 at 12:00 a.m. During interview with the Corporate Minimum Data Set (MDS) Registered Nurse (RN) on 01/21/16 at 10:10 a.m., she stated that care plans were reviewed and updated with each Annual MDS assessment. During further interview, she stated that when this was done, the new falls care plan would not include all of the falls information from the previous falls care plan.

Based on observation, record review, review of the facility's Skin Care Guidelines and Skin Assessment Guidelines and staff interview, it was determined that the facility failed to ensure that pressure relieving measures to prevent pressure sores were initiated and implemented to prevent the development of pressure sores and promote the healing of pressure sores; failed to conduct weekly skin assessments in order to identify the development of pressure sores timely in order to initiate treatment promptly; and failed to ensure that dressings were monitored in order to promptly apply a clean dressing to an exposed pressure sore to prevent contamination for three (3) residents (#7, S and #25) of five (5) residents reviewed for pressure sores from a total sample of thirty (30) residents. This failure to identify the development of pressure sores timely resulted in harm for residents S and #25 who developed unstageable Deep Tissue Injuries (DTIs) prior to staff identification of the pressure sores. Findings include: 1. Resident #25 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 9 indicating that the resident was cognitive with confusion, was non-ambulatory, required total assistance from staff for bed mobility, transfer, eating, personal hygiene, bathing and toileting and was always incontinent of bowel and bladder. Review of the resident's care plan dated 4/11/15 and reviewed 7/21/15 and 10/6/15 revealed that the resident was at risk for skin breakdown related to decreased mobility, history of pressure sores, diabetes, venous stasis disease, refusal to be turned and repositioned and incontinence of bowel and bladder. Interventions included certified nursing staff to observe the resident's skin during showers and activities of daily living (ADL) care for early signs of breakdown and to notify the charge nurse and for the charge nurse to conduct skin assessments per facility protocol. Review of the facility's Skin Assessment Guidelines revealed that each resident was supposed to be provided a head to toe skin assessment during baths by their assigned Certified Nursing Assistant (CNA). The CNA completed the skin assessment on the CNA Skin Assessment Checklist form and gave the form to the charge nurse and/or treatment nurse. Review of the Skin Care Guidelines revealed that each resident would be assessed by the nurse for potential skin problems on admission, readmission and quarterly or if there was a change in the resident's condition. The charge nurse would conduct a head to toe skin assessment for low and moderate risk residents with each monthly nursing summary following the monthly schedule posted at each nurses station. The Care Plan Coordinator would update the resident's skin risk assessment with each quarterly Minimum Data Set (MDS) or change in condition. Any changes in score that caused a resident to become high risk, the MDS coordinator would notify the Director of Nursing (DON). The DON and/or MDS coordinator was responsible for updating the High Risk Assessment book to be picked up by the nurses who were assigned to conduct weekly skin assessments. Resident's at high risk for skin breakdown would have weekly skin assessments performed by the charge nurse. The charge nurse was also responsible for ensuring that the residents were turned and repositioned every two hours and that proper pressure relieving devices were used. Review of the Pressure Ulcer Risk Assessment form reviewed on 1/6/15, 3/26/15, 5/26/15, 8/18/15 and 12/2/15 revealed that Resident #25 scored 14 to 15, indicating that the resident was at high risk for the development of pressure sores. Review of the Bath Schedule Book revealed that the resident was supposed to receive showers on the 7:00 a.m. to 3:00 p.m. shift every Tuesday, Thursday and Saturday. Review of the Weekly Skin Assessment Schedule Book revealed that licensed nursing staff were supposed to perform a head to toe skin assessment of the resident every Monday on the 11:00 p.m. to 7:00 a.m. shift. review of the resident's medical record revealed [REDACTED]. Although it was facility policy to perform a head to toe skin assessment on all residents readmitted to the facility, there was no indication that licensed or registered nursing staff had performed a head to toe skin assessment on the resident on 6/26/15 when he/she returned from the hospital. Review of the Nurses Note dated 7/21/15 revealed that the resident had a decline in condition, was total care for all activities of daily living (ADLs), was fed all meals and had poor intake, was having hallucinations, was incontinent and without skin breakdown at that time. Review of the Nurses Note dated 7/23/15 revealed that the resident's weight was down 7.2 pounds (#) from his/her previous weight of 177.7# on 7/16/15. Staff initiated Boost Glucose Control (a supplement) twice a day for thirty (30) days to prevent further weight loss. Further review of the medical record revealed that the Registered Dietician (RD) assessed the resident on 8/11/15 and recommended a Multivitamin with minerals every day, a House Shake (supplement) at bedtime for ninety (90) days and Boost Glucose Control for thirty (30) days to promote healing of the pressure sore and prevent further weight loss. On 1/28/16 at 11:52 a.m., the Licensed Practical Nurse (LPN) Treatment Nurse provided a Skin Assessment form and note dated 7/26/15 that revealed that the resident was identified with a 2 centimeter (cm.) by 2 cm. by <0.2 cm. dark maroon Deep Tissue Injury (DTI) on his/her left heel that was without drainage. The physician was notified at that time and treatment initiated. Continued review of the resident's medical record revealed [REDACTED]. Review of the Weekly Pressure Ulcer QI Log dated 7/30/15 revealed that interventions to assist with healing of the DTI included heel protectors. However, review of the resident's medical record prior to the identification of the DTI on 7/26/15 revealed that there was no indication that staff had initiated any pressure relieving devices to prevent skin breakdown until after the resident developed the DTI on his/her left heel. Furthermore, there was no indication that certified nursing staff had assessed the resident's skin every bath/shower day as care planned or that licensed nursing staff had performed weekly skin assessments as per facility policy in order to identify potential breakdown promptly and initiate treatment timely. The LPN Treatment Nurse could only provide two CNA Skin Assessment Check List forms prior to the identification of the DTI on 7/26/15 that were dated 7/16/15 and 7/17/15 and were incomplete regarding the presence or absence of breakdown. Interview with the LPN Treatment Nurse on 1/28/16 at 10:50 a.m. revealed that she was unable to locate any of the weekly skin assessments that licensed nursing staff were supposed to perform on the resident prior to the identification of the DTI on 7/26/15. Continued interview with the LPN Treatment Nurse revealed that she was responsible for ensuring that the CNAs and the nurses completed the skin assessments. Interview with Certified Nursing Assistant (CNA) PP on 1/28/16 at 1:20 p.m. revealed that she/he assessed the resident's skin on shower days and also on other days when the resident received a bedbath. Continued interview revealed that PP documented on the CNA Skin Assessment Checklist form and would notify the nurse if she/he saw any redness or open areas. Interview with Licensed Practical Nurse (LPN) AA on 1/28/16 at 1:55 p.m. revealed that the nurses were supposed to perform weekly skin assessments but, were sometimes unable to perform as scheduled because staff were swamped. On 1/28/16 at 12 noon, the resident was lying in the bed with bilateral heel protectors on. On 1/28/16 at 2:05 p.m., the LPN Treatment Nurse provided treatment to the resident's left heel DTI as ordered by the physician. The DTI on the resident's left heel measured 0.8 cm. by 0.8 cm. by <0.2 cm. with soft black wound bed and no odor or drainage. Although the resident was assessed as being at high risk for the development of pressure ulcers on 1/6/15, 3/26/15 and 5/26/15, there was no indication that certified nursing staff consistently assessed the resident's skin on shower/bath days as care planned prior to the identification of the DTI on the resident's left heel on 7/26/15. There was no indication that licensed nursing staff assessed the resident's skin weekly as per facility policy prior to the identification of the DTI on the resident's left heel on 7/26/15. There was no indication that licensed nursing staff had performed a head to toe skin assessment of the resident on his/her 6/26/15 readmission from the hospital as per facility policy. Although staff had identified that the resident had a decline with poor intake and total care for activities of daily living (ADLs) on 7/21/15, there was no indication that staff had initiated heel booties as an effective pressure relieving measure to prevent the development of a pressure sore on the resident's heel until after the development of the DTI on 7/26/15. 2. Resident S was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 15, indicating that he/she was alert and oriented. Continued review revealed that the resident was non-ambulatory, required extensive assistance from staff for bed mobility, transfer and bathing and was always incontinent of bowel and bladder. Further review revealed that the resident had a fall with major injury, had limitations on one side of his/her lower extremities and was at risk for the development of pressure sores. Review of the resident's care plan dated 2/16/15 revealed that he/she had the potential for skin breakdown related to limited mobility with interventions for certified nursing staff to observe the resident's skin during showers/ADL care for early signs of skin breakdown and notify the charge nurse and for licensed nursing staff to perform skin assessments per facility protocol. Review of the facility's Skin Assessment Guidelines revealed that each resident was supposed to be provided a head to toe skin assessment during baths by their assigned Certified Nursing Assistant (CNA). The CNA completed the skin assessment on the CNA Skin Assessment Checklist form and gave the form to the charge nurse and/or treatment nurse. Review of the Skin Care Guidelines revealed that each resident would be assessed by the nurse for potential skin problems on admission, readmission and quarterly or if there was a change in the resident's condition. The charge nurse would conduct a head to toe skin assessment for low and moderate risk residents with each monthly nursing summary following the monthly schedule posted at each nurses station. The Care Plan Coordinator would update the resident's skin risk assessment with each quarterly Minimum Data Set (MDS) or change in condition. Any changes in score that caused a resident to become high risk, the MDS coordinator would notify the Director of Nursing (DON). The DON and/or MDS coordinator was responsible for updating the High Risk Assessment book to be picked up by the nurses who were assigned to conduct weekly skin assessments. Resident's at high risk for skin breakdown would have weekly skin assessments performed by the charge nurse. The charge nurse was also responsible for ensuring that the residents were turned and repositioned every two hours and that proper pressure relieving devices were used. review of the resident's medical record revealed [REDACTED]. Review of the 6/15/15 and 6/18/15 nurses' notes revealed that the resident was readmitted with an immobilizer between his/her legs. Review of the Pressure Ulcer Risk Assessment form dated 6/24/15 revealed that the resident scored 13, indicating that she/he was at high risk for the development of pressure sores due to the resident being bedfast and presence of [MEDICAL CONDITION]. Continued review of the resident's medical record revealed [REDACTED]. Review of the Physical Therapy Discharge Summary for 6/15/15 to 6/26/15 revealed that the resident was ambulating five (5) feet with maximum assist when she/he was discharged to the hospital on [DATE]. Further review of the resident's medical record revealed [REDACTED]. After readmission from the hospital on [DATE], the resident continued with skilled therapy. Review of the nurses notes after 7/1/15 revealed that the resident was occasionally turned and repositioned every two hours but, there was no indication that any additional preventive measures were in place to prevent breakdown. Review of the Skilled Daily Nurses Note dated 7/14/15 at 12:30 p.m. revealed that the resident was observed with a new Deep Tissue Injury (DTI) on his/her left heel and that the treatment nurse was notified. Review of the Weekly Pressure Ulcer Record and the Nurses Note dated 7/14/15 revealed that the DTI measured 3 cm. by 3 cm. by <0.2 cm. with a dark red and maroon wound bed and small amount serosanguinous drainage. Continued review revealed that the tissue surrounding the wound bed was macerated and the heel was tender to the touch. Further review revealed that the resident's left lower leg was red and warm with 4+ [MEDICAL CONDITION] and the resident's right lower leg had 3+ [MEDICAL CONDITION]. The physician was notified and ordered Keflex 500 milligrams (mgs.) twice a day for ten (10) days for [MEDICAL CONDITION]. The physician also ordered staff to clean the DTI on the resident's left heel with normal saline, to apply skin prep and dry dressing every day and as needed; if the pressure sore did not have any excessive drainage, licensed nursing staff could leave the DTI open to air. Continued review of the Weekly Pressure Ulcer Record dated 7/14/15 revealed that preventive measures included turning and repositioning the resident every two hours, administration of a multivitamin and a heel protector on the resident's left foot. Review of the resident's care plan revealed that new interventions for bilateral heel protectors and to off-load heels were added after the pressure sore was identified. Weekly assessments of the DTI were obtained to include staging, measurements and description of the pressure sore. Review of the Treatment Records revealed that treatments were done as ordered by the physician. Review of the Dietary Progress note dated 8/17/15 revealed that the Registered Dietician recommended Prostat 30 cubic centimeters (cms.)twice a day for decreased [MEDICATION NAME] level of 2 on 8/7/15 (normal range was between 3.5-5). Further review of the Weekly Pressure Ulcer Record dated 9/1/15 revealed that the DTI had increased in size to 4.6 cms. by 4.4 cms. by 1.0 cm. Further review of the resident's medical record revealed [REDACTED]. On 1/19/16 at 4:44 p.m. and on 1/20/16 at 10:31 a.m., the resident was observed with a heel protector on his/her left heel and his/her left foot was elevated. On 1/20/16 at 10:51 a.m., Licensed Practical Nurse (LPN) Treatment Nurse removed the dressing dated 1/19/15 from the resident's left foot. The dressing had a moderate amount of serosanginous drainage without odor. The LPN Treatment Nurse provided treatment to the pressure sore on the resident's left heel as ordered by the physician. The pressure sore measured 2.8 cms. by 4.7 cms. by 0.2 cm. and appeared as a Stage IV pressure sore with pink granulation tissue in the wound bed. An assessment of the resident's right foot revealed no redness or breakdown. Review of the facility's Skin Assessment Guidelines revealed that each resident would receive a head to toe assessment by the charge nurse on duty at the time of admission, with any significant change, or upon return from a hospital stay. Continued review revealed that any resident at high risk of developing a pressure sore was provided a head to toe skin assessment weekly by the treatment nurse or RN/LPN. Further review revealed that each resident was provided a head to toe assessment during the delivery of a bath by their assigned Certified Nursing Assistant (CNA). Review of the facility's Skin Care Guidelines revealed that residents would be assessed on admission, readmission and quarterly for potential skin problems and more often if there was a change in condition. The Care Plan Coordinator would update the skin risk assessment with each quarterly MDS or change in condition. The MDS coordinator would notify the Director of Nursing (DON) of any changes in score that caused a resident to become high risk for pressure sore development. It would be their responsibility to update the high risk assessment book to be picked up by the nurses who were assigned to do weekly skin assessments. Interview with Certified Nursing Assistant (CNA) NN on 1/21/16 at 2:35 p.m. revealed that she/he assessed a resident's skin during care, baths and showers for any breakdown or redness and would notify her/his nurse if any change was observed. Continued interview with NN revealed that she/he provided incontinence care for the resident every two hours and ensured that the resident wore his/her heel booties. Interview with LPN Treatment Nurse on 1/22/16 at 11:25 a.m. revealed that she could not find the Readmission Assessment Form dated 7/1/15 when licensed nursing staff would have assessed the resident's skin on readmission from the hospital. Review of the CNA Skin Assessment Checklist forms provided by the LPN Treatment Nurse revealed that the earliest was dated 7/7/15 and had incomplete documentation regarding the presence or absence of any skin condition. Continued interview with LPN Treatment Nurse at that time revealed that she had reviewed the Licensed Nurse Skin Assessment Book and could not find any weekly skin assessments performed by licensed nursing staff prior to the identification of the DTI on the resident's heel on 7/14/15. Further interview revealed that she obtained the CNA Skin Assessment Checklist Forms and the Weekly Skin Assessment Forms completed by licensed nursing staff at the end of each week and kept the forms in a notebook in the copy room. Further interview revealed that she was responsible for ensuring that the nurses were completing the weekly skin assessments. Review of the Skin Assessment Book for Unit II on 1/27/16 at 1:29 p.m. revealed that the resident was supposed to have a weekly skin assessment on the 3:00 p.m. to 11:00 p.m. shift every Friday. Review of the Unit II Shower Sheet Book revealed that the resident received a bath every Monday, Wednesday and Friday on the 7:00 a.m. to 3:00 p.m. shift. Interview with LPN GG on 1/27/16 at 1:35 p.m., revealed that the CNAs completed their skin assessments on residents every bath and shower day and documented on the CNA Skin Assessment Checklist form. Further interview revealed that the nurses signed off on the form and would report to the Treatment Nurse of any changes in a resident's skin right away. Continued interview with GG revealed that if she/he observed breakdown during her/his weekly skin assessments, she/he would notify the physician for treatment orders, initiate treatment and notify the treatment nurse. Although the resident was assessed as being at high risk for the development of pressure ulcers on 6/24/15, there was no indication that certified nursing staff consistently assessed the resident's skin on shower/bath days as care planned prior to the identification of the DTI on the resident's left heel on 7/14/15. There was no indication that licensed nursing staff assessed the resident's skin weekly as per facility policy prior to the identification of the DTI on the resident's left heel on 7/14/15. There was no indication that licensed nursing staff had performed a head to toe skin assessment of the resident on his/her 7/1/15 readmission from the hospital as per facility policy. Although staff had identified that the resident was extensive care after his/her fall with left [MEDICAL CONDITION] on 6/9/15, there was no indication that staff had initiated heel booties as an effective pressure relieving measure to prevent the development of a pressure sore on the resident's heel until after the development of the DTI on 7/14/15. 3. Review of a Pressure Ulcer Risk Assessment for resident #7 dated 11/13/15 noted that the resident was assessed as high risk for developing pressure ulcers. Review of their severe risk for skin breakdown/pressure sores care plan revealed interventions for a cushion to the chair, and for nurses to perform weekly skin assessments. Review of the facility's Skin Care Guidelines Policy and Procedure noted that high risk residents are assigned to have weekly skin assessments by the RN/LPN (Registered Nurse/Licensed Practical Nurse) or treatment nurse. Continued review of the Policy and Procedure revealed that residents identified as high risk will have appropriate measures with necessary orders recorded and written by the treatment nurse, and the charge nurse will be responsible for proper use of positioning devices such as pillows or wedges. Review of Weekly Pressure Ulcer Records noted the resident developed two Stage II pressure ulcers on 11/18/15, one on each trochanter area over the bony prominences. Review of Skin Assessment Forms completed by licensed nurses revealed no skin breakdown on 10/02/15; 10/10/15; 10/22/15; and 10/29/15. Review of the next Skin Assessment Form provided was dated 11/18/15, and noted treatment to left and right trochanters. During interview with the LPN Treatment Nurse on 01/20/16 at 10:14 a.m., she stated that resident #7 developed pressure ulcers to both trochanters in the facility, that the dressing change order was for it to be done every three days, and that the last time she changed the dressing was on 01/17/16. During interview with the LPN Treatment Nurse on 01/20/16 at 1:59 p.m., she stated that skin assessments were done weekly by the staff nurse. During interview with the LPN Treatment Nurse on 01/21/16 at 12:46 p.m., she stated that the skin assessments she provided were all of the ones she had for October and November, and verified there were none done by a nurse for the two weeks prior to development of the pressure ulcers. During observation of wound care at this time, there were no dressings to either trochanter when the incontinent brief was removed. During interview with the LPN Treatment Nurse at this time, she stated the last time she observed the dressing to ensure it was intact was on 01/18/16. During observations of resident #7 in her wheelchair, no pressure-reduction cushion was noted in the seat on 01/19/16 at 4:50 p.m.; 01/20/16 at 7:45 a.m. and 10:14 a.m.; 01/21/16 at 12:41 p.m. and 2:24 p.m.; 01/22/16 at 10:49 a.m.; and 01/25/16 at 9:18 a.m. During interview with Certified Nursing Assistant (CNA) EE on 01/21/16 at 11:22 a.m., she stated that she knew the resident's care needs because it was in a notebook at the nurse's station. Review of this notebook revealed a page which listed all residents who should have a cushion in the seat of their wheelchair, and resident #7 was not on this list. During further interview with CNA EE, she stated the resident had a seat cushion at one time, but did not have one now. During interview with CNA JJ on 01/22/16 at 10:49 a.m., she verified there was no cushion in the seat of resident #7's wheelchair.