Every finding on record at Miami Jewish Health Systems, Inc

Based on observations, records reviewed and interviews, the facility's staff failed to adequately supervise one (Resident #1) of two vulnerable residents sampled had falls resulting in injuries. On 02/25/2026 vulnerable Resident #1 was left unattended in an unlocked wheelchair by Certified Nursing Assistant Staff A; the wheelchair rolled away and Resident #1 fell from the wheelchair, hit his head on the pavement and sustained major head injuries. There were 235 residents residing in the facility at the time of survey. The findings included: Observation on 3/18/26 at 11:42 AM of the facility's video footage dated 2/25/2026 timestamped 2:30 PM showed Staff A, Certified Nursing Assistant (CNA) escorting Resident #1who was seated in a wheelchair to the door of the auditorium. Staff A, CNA left Resident #1 at the door, did not lock the wheelchair and went inside the auditorium leaving Resident #1 outside. While Staff A, CNA was inside the auditorium, Resident #1's wheelchair started rolling until it came in contact with the sidewalk and Resident#1 fell out of the wheelchair and hit the pavement. A few moments later Staff A, CNA exited the auditorium and checked on Resident #1. Record review of nursing notes dated 2/25/2026 revealed Resident #1 was assessed at approximately 2:30 PM downstairs near the auditorium and found to have sustained a laceration to the left forehead with significant bleeding. An ambulance arrived and transported the resident to a nearby hospital for further evaluation.Record review of nursing notes dated 2/26/2026 indicated the hospital was contacted and revealed Resident#1 had a diagnosis of cerebral brain bleed.Clinical records revealed Resident #1 was admitted to the hospital from [DATE] and returned to the facility on [DATE].Review of Resident #1's hospital records after the incident indicated the resident sustained a contusion and laceration of the cerebrum and brain hemorrhage.Review of Resident #1's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Fall from non-moving wheelchair, Contusion and Laceration of Cerebrum and injury without loss of consciousness, Diffuse Traumatic brain injury with loss of consciousness, Dementia, Functional Quadriplegic and Left-hand Contracture. Record review of Resident #1's fall scale assessments dated 2/15/22, 4/11/22, 4/16/22, 7/17/22, 8/10/22, 3/1/26, 2/04/24, 11/23/25, and 2/23/26 revealed Resident#1 was at a High Risk for falls. Review of Resident #1's fall history revealed the resident sustained falls on 04/11/2022, 04/16/2022, 08/09/2022, 02/04/2024, 02/15/2024 and 02/25/26.Record review of Resident #1's Order Summary Report revealed orders dated 11/20/24 to provide falls precautions as care planned every shift for prevention of falls.Record review of care plans initiated: 02/21/2022 and revised: 02/05/2024 problem focus indicated Resident #1 is at high risk for falls related to history of falls, impaired mobility, difficulty communicating needs, unsteady gait, poor safety awareness, muscle weakness, left side weakness, side effects of psychotropic medications, overestimates ability, adamant to keep his independence with interventions that included: Close supervision, encourage resident to stay in supervised area when in wheelchair and provide safety reminders during rounds and offer assistance with toileting and care. Record review of a Discharge Return Anticipated Minimum Data Set reference dated 2/25/2026 Cognitive Section revealed a Brief Interview of Mental Status (BIMS) score of three out of fifteen indicating severely impaired cognition; Functional Abilities and Goals section indicated Resident #1 required substantial/maximal assistance for toilet transfer/ sit to stand/ chair/bed-to-chair transfer. During a telephone interview on 3/18/26 at 11:26 AM Staff A, CNA stated: [Resident#1] asked to be taken to the auditorium, so I took the resident to the door of the auditorium asked [Resident#1] to wait while I looked inside. When I returned, I saw [Resident#1] was on the ground, laying on stomach. I went inside to get help, and the Patient Assessment Team was called and assessed the resident. I saw there was a cut on the side of the resident's face. Emergency services came and took the resident to the hospital. I don't remember locking the wheelchair. I am aware the wheelchair should be locked. On 3/18/26 at 2:11 PM Resident #1 was observed in the dining room area seated in a wheelchair next to Staff B, CNA. Resident #1 did not respond when greeted and showed little to no facial expressions and a scar was noted on the left side of his forehead.Interview on 3/18/26 at 2:12 PM Staff B, CNA stated, I am the one to one (1:1) monitor assigned to [Resident #1]. I assist the resident with all the ADLs (Activities of Daily Living ) and sometimes the resident talks to me. I notice this resident did not need as much assistance before the fall.Interview on 3/18/25 at 2:15 PM Staff C, Licensed Practical Nurse (LPN) stated, I am the nurse assigned to [Resident #1] today and since the resident returned, I have noticed a slower response time. He now requires maximum assistance.During an interview on 3/18/2026 at 3:25 PM the Risk Manager stated: I was informed about the fall on 2/25/2026 and [Resident #1] was transferred to the hospital and the next day a report was received that a cerebral bleed was sustained, at that time I reported it to state agencies. It was initially reported to me that [Resident #1] attempted to get out the wheelchair however the CNA involved could not remember if the wheelchair was locked. I viewed the video footage that confirmed the wheelchair was not locked and determined to be negligent on our part. During that time Staff A, CNA was placed on administrative leave.Review of the facility's Policy titled Fall Prevention Effective Date: 12/1990 with Revision Dates 03/2020 and 03/2022 indicated:PURPOSE: To ensure the safety and well-being of all Miami Jewish Health residents by identifying risk factors and interventions to reduce the likelihood of Falls.POLICY: It is the policy of Miami Jewish Health to take steps to reduce the number and severity of resident falls through appropriate assessment, evaluation, investigation, root cause analysis, identification of risk factors, and interventions that are appropriate for the resident, in order to prevent occurrence, re-occurrence and reduce the likelihood of significant injury.

Based on observation, records reviewed and interviews, the facility failed to ensure narcotics/ controlled substances were reconciled for one ([NAME] 3, Medication Cart #2) out of ten medication carts observed in the facility. There were 288 residents residing in the facility at the time of this survey.The findings include. On 09/17/2025 at 10:00 AM during the narcotic count and review of [NAME] (3) Medication Cart #2 with Licensed Practical Nurse (Staff I), the narcotic count was inaccurate for Resident # 127's Clonazepam oral tablet 1milligrams (mg). The narcotic count sheet revealed that the last tablet was signed out as given at 10:00 PM on 09/16/25 and the remaining tablets noted as 19. The bingo card/packet count was 18. In addition, the narcotic count was inaccurate for Resident # 255's Lacosamide Oral Tablet 100 milligrams (mg) tablet. The narcotic count sheet revealed that the last tablet was signed out as given at 06:39 PM on 09/16/25 and the remaining tablets noted as 56. The bingo card/packet count was 55. Licensed Practical Nurse (Staff I) acknowledged the discrepancies and revealed she forgot to sign out the medication and was trying to sign out the medications before the surveyors got to her cart. Licensed Practical Nurse (Staff I) proceeded to sign out the medication (Lacosamide 100 mg, 1 tablet on the bingo card as given on 9/17/25 at 9:30AM. Review of the Electronic Medication Administration Record (EMAR) revealed Resident # 127's Clonazepam oral tablet 1milligrams (mg), (1) tablet was given on 09/17/25 at 9:00 AM and Resident #255's Lacosamide Oral Tablet 100 milligrams (mg), (1) tablet was given on 09/17/25 at 9:00 AM. Interview on 09/17/25 at 10:05 AM Licensed Practical Nurse (Staff I) revealed the facility's policy is to sign out narcotic medications immediately after taking medications from the bingo card and document as given after the medication has been taken by the resident; and she just did not get around to signing off the medications.Interview on 09/18/25 at 3:30 PM the Director of Nursing (DON) revealed on 09/16/25 they had started Performance Improvement Plans for identified concerns regarding medication administration procedures, protecting Personal Health Information (PHI), signing out control substances. Review of the facility's policy and procedure titled Disposal of Medications and Medication-Related Supplies dated May 2022 states: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state laws and regulations.

Based on observations, record reviews and interviews, the facility failed to secure residents' confidential information on two ([NAME]-1st floor, Medication Cart 1 and 5th floor, Medication Cart 2) out of four medication carts: as evidenced by unattended Medication Carts noted with unlocked computer screens displaying residents' confidential information during medication administration. There were 288 residents residing in the facility at the time of the survey.The findings included: Observation on 09/16/2025 at 9:47 AM, on the 5th floor, revealed Medication Cart 2 was left unattended and the computer's screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff C, Registered Nurse (RN) of the identified concern. Staff C, RN revealed she did not realize she had left the computer screen open. On 09/16/2025 at 10:15 AM, observation on the 1st floor revealed Medication Cart 1 unattended and the computer screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff D, RN of the identified concern. Staff D, RN revealed he only stepped a few feet away from the computer to assist a resident and came right back. Record review of a Policy titled, Preparation and General Guidelines: May 2022 indicate:Policy: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. In addition, privacy is maintained always for all resident information (e.g., Medication Administration Record (MAR) [by closing the MAR book/covering the MAR sheet or computer screen when not in use.Interview on 09/16/2025 at 02:10 PM, the Director of Nursing (DON) stated: During medication pass, the staff member provides privacy depending on the situation and always asks the resident if it is acceptable first. To ensure privacy, the staff either pulls the resident away from others or brings them back to their room. In shared rooms, curtains and doors are closed. Medications may be administered in the activity room, but only with the residents' consent. Before leaving the cart, the staff member locks it and ensures all resident information is secure. The computer screen is never left open unattended and locks automatically every 30 seconds.Interview on 09/16/2025 at 9:47 AM, Staff C, RN stated: I did not realize I left the computer screen open. I receive frequent education from the nurse educator about privacy and HIPAA.Interview on 09/16/2025 at 10:15 AM, Staff D, RN stated: I only stepped a few feet away from the computer to assist a resident and came right back. I have only been a nurse here for one month and recently received education on privacy and HIPPA recently for my training virtually and by my preceptor.

Based on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for two (Resident #209 and Resident #302) out of 35 residents sampled. As evidenced by Resident #209's Incentive Spirometer and Resident # 302's Bilevel Positive Airway Pressure (BIPAP) machine was observed stored at bedside with no protective covering. The findings include.During observation on 09/16/2025 at 11:47 AM Resident #209 was in bed awake, oxygen (02) running at two (2) Liters per minute (Lpm), Incentive spirometer stored on bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 11:00 AM and on 09/18/2025 at 01:27 PM the Incentive Spirometer was noted on the bedside table in a resealable plastic bag dated 09/17/25.Review of Resident # 209 medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Chronic Obstructive Pulmonary disease, Chronic Respiratory Failure with Hypoxia.Observation on 09/16/2025 at 11:51 AM Resident # 302 was in bed awake, a BIPAP machine noted on the bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 10:58 AM and on 09/18/2025 at 2:36 PM the BIPAP machine was observed on the bedside table in a resealable plastic bag dated 09/17/25.Review of the medical records for Resident # 302 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Acute and Chronic Respiratory Failure with HypoxiaInterview on 09/18/25 at 11:18AM Registered Nurse (Staff G) assigned to Resident # 209 and Resident # 302 reported that all respiratory equipment when not being used are stored in a dated [brand] bag, the [brand resealable plastic bags] are changed weekly on Sundays and as needed. We store respiratory equipment in [brand resealable plastic bags] to prevent infection to the residents. During my shift I conduct rounds for my residents every two hours and sometimes more often depending on the resident.Interview on 09/18/25 at 11:26 AM Licensed Practical Nurse (Staff F) assigned to Resident # 209 and Resident # 302's unit revealed, respiratory equipment when not being used is stored in a dated [brand resealable plastic bag], the [brand resealable plastic bags] are changed weekly and as needed. The reason for storing the respiratory equipment in the [brand resealable plastic bag] is to prevent infection. During my shift I check on my residents every one to two hours, high risk residents are checked on every thirty (30) minutes.Interview on 09/18/25 at 11:35AM Registered Nurse Unit Manager (Staff H) was shown photographic evidence. Staff H stated: I will reeducate all the nursing staff on infection control procedures. Respiratory equipment is stored in a dated [brand resealable plastic bag] and changed weekly. The date on the [brand resealable plastic bag] is the date the bag was changed.Review of the facility policy and Procedure titled Infection Prevention and Control Plan dated February 2022 states: The facility maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and accrediting agencies.

Based on observation, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for one (Resident # 55) out of one sampled resident who has a primary diagnosis of Acute Respiratory Failure. As evidenced by the resident's nasal canula (NC) was not in nostrils. The findings included.Observation on 09/16/2025 at 11:07 AM, Resident #55 was in bed with eyes closed, Oxygen (02) running at two (2) Liters per Minute (LPM) via Nasal Canula (NC), NC not in resident's nostrils. The surveyor requested to see the assigned nurse in resident's room.On 09/16/2025 at 11:14 AM Licensed Practical Nurse (Staff F), positioned the 02 tubing in the resident's nostrils, checked the resident's oxygen saturation on the right index finger, the reading was100.On 09/17/2025 at 10:53 AM, Resident #55 was observed in bed, receiving morning care, 02 running at 2 LPM via NC, nasal tubing position correctly in nostrils.During observation on 09/18/2025 at 10:00 AM, Resident #55 noted in room receiving morning care from staff, 02 tubing positioned in nostrils, no distress noted.Review of the medical records for Resident #55 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Atherosclerotic Heart Disease of Native coronary Artery without Angina Pectoris.Review of the Physician's Orders Sheet for September 2025 revealed Resident #55 had orders that included but not limited to: Oxygen 2 LPM via nasal cannula continuous-every shift for shortness of breath.Record review of Resident # 55's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments and Procedures documented the resident is receiving oxygen therapy.Review of Resident #55 Care Plans Reference Date 06/26/25 documented: The resident is on oxygen therapy continuously every shift for shortness of breath, 02 less than 94%. The resident will have no sign and symptoms of poor oxygen absorption through the review date. Interventions include-Change residents position every 2 hours to facilitate lung secretion movement and drainage.Interview on 09/16/2025 at 11:20 AM Licensed Practical Nurse (Staff F) revealed the resident is not alert and oriented and is nonverbal, so education with the resident has not been completed. Staff F stated: I do frequent rounds for this resident because he takes his oxygen tubing off sometimes. Staff F reported she does not know if this a regular behavior for the resident because she does not work with the resident regularly.Interview on 09/16/2025 at 11:38AM, Registered Nurse, Nurse manager (Staff H) stated: This resident pulls his tubing off frequently, the staff have been educated to check on the resident often. The resident is not alert oriented and is non-verbal. As a result, education has not been provided to the resident. All we can do is frequent rounds checking on the resident and alert the nurse if the resident's nasal canula needs to be repositioned correctly.Review of the facility policy and procedures titled, Oxygen Administration revision date November 18, 2024, states: Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. In patients with hypoxemia, the cardiopulmonary system compensated by increasing ventilation and cardiac output. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. Reducing cardiac workload is especially important when disease or injury-such as myocardial infarction (MI), sepsis, or traumas already stressing the heart. Hypoxemia causes pulmonary vasoconstriction and subsequent pulmonary hypertension, which increases the workload of the right side of the heart. Oxygen administration can reverse pulmonary vasoconstriction, decreasing right ventricular workload. Oxygen administration has only limited benefit for treatment of hypoxia caused by anemia because of the blood's limited oxygen-carrying capacity.

Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for two (Residents #5 and #6) out of three residents sampled, as evidenced by Resident # 5 and Resident # 6 had wander/elopement alarm devices on their left ankle as ordered. However, the Annual MDS indicated the devices were not used. There were 306 residents residing at the facility at the time of the survey. The findings included: Resident #5: On 06/02/2025 at 12:40 PM Resident #5 was observed in the dining room, sitting in her wheelchair eating independently. Review of Resident #5's medical records revealed the resident was initially admitted to the facility on admitted to the facility on [DATE]. Clinical diagnoses include Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and Alzheimer's disease. Review of Resident # 5's Physician's Orders Sheet and Electronic Treatment Administration Records for June 2025 revealed an order with start date 11/09/2023 for Electronic wandering device to the left ankle. Check if the device is in place and functioning every day shift every Thursday for Elopement risk and every shift. Review of Resident #5's Care Plans initiated 10/26/2023, revision dated 05/28/2025, target date 07/21/2025, revealed Resident #5 is at risk for elopement or wandering related to impaired safety awareness, Resident wanders aimlessly. Interventions include- Assess resident for risk of elopement or wandering. Resident has wandering device in place to left ankle and will be checked every Thursday. Review of Resident #5 's Annual MDS assessment dated [DATE] indicated in Section C for Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 to suggest severe cognitive impairment. Section P- Restraints and Alarms-P0200-Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts; Item E-Wander/elopement alarm coded 0=Not used. Resident #6: On 06/02/2025 at 12:45 PM, Resident #6 was observed in common area sitting in her wheelchair eating lunch supervised by staff. Review of the medical records for Resident #6 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and Schizoaffective disorder bipolar type. Review of Resident #6's Physician's Orders Sheet for June 2025 revealed order dated 04/13/2023 and 04/04/2025 for: Electronic wandering device to the left ankle. Check if the device is in place and functioning every day shift every Thursday for Elopement risk and every shift. Record review of Resident #6's Care Plans initiated 12/11/2021, Revised 04/22/2025; Target date 09/02/2025 revealed Resident #6 is at risk for exit seeking behaviors related to cognition and disorientation to place, she has impaired safety awareness due to dementia. Interventions include- Check wandering left ankle for functioning and placement. Distract resident from wandering by offering pleasant diversions, structured activities . Record review of Resident #6 's Annual MDS assessment dated [DATE] revealed in Section C for Cognitive Pattern indicates a Brief Interview for Mental Status (BIMS) score of 03 out of 15 to suggest severe cognitive impairment. Section E for Behavior documented verbal behavioral symptoms occur 1 to 3 days and rejection of care occurs 4 to 6 days. Section P- Restraints and Alarms/P0200-Alarms: An alarm is any physical or electronic device that monitors resident movement and alerts; Item E-Wander/elopement alarm coded 0=Not used. Interview on 06/02/25 at 02:00 PM with Staff A, MDS Coordinator stated: The [Wander Alert Device] are coded under section P in the MDS. I code them once the MDS is completed and if the resident is wearing the device at the time of the assessment. [Residents #5 and #6] were miscoded and it was an oversight . Review of the facility's policy and procedure dated March 2022 indicate it is the policy of Miami Jewish Health to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of all residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized.

Based on observations, record review and interviews facility failed to administer medications as ordered by a physician in accordance with professional standards for two residents (Resident #1 and Resident #6) out of four sampled residents as evidenced by staff failed to administer an accurate dose of a laxative for Resident #1 and failed to administer a blood pressure lowering medication as ordered for Resident #1. The findings included: Observation on 2/25/25 at 9:12 AM of Resident # 6's medication administration being completed by Staff B, Registered Nurse (RN) revealed the medications administered by mouth included Lactulose 15 ml (milliliters). The label on the bottle of Lactulose read 30 ml daily by mouth (photographic evidence). Review of Resident #6's physician orders revealed order dated 2/21/25: Lactulose Oral Solution 10 gm/15 ml (grams/milliliters) directions: Give 15 ml by mouth in the morning for constipation. Record review of Resident #6's demographic sheet revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include constipation. Review of Resident #6's Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15 to indicate moderate cognitive impairment. During an interview on 2/25/25 at 1:45 PM, Staff B, RN was asked about the discrepancies in the label on the Lactulose bottle and the current order noted on the Electronic Medication Administration Record (MAR). At that time Staff B, RN referred to the physical chart and presented a physician orders worksheet dated 2/21/25; the document presented revealed physician ordered to lower Lactulose to 10cc daily. Interview on 2/25/25 at 2:45 PM with the Director of Nursing (DON) about The Lactulose order for Resident # 6; the DON stated: The Lactulose order was clarified with the physician and the order should have been 10 ml daily. An incident report was completed. [Resident #6] was not harmed. Review of a demographic sheet for Resident#1 revealed an admitted [DATE], readmitted [DATE], discharge date s of 2/4/25 and 2/14/25 with diagnosis that included: Hypertensive Heart Disease and Chronic Kidney Disease. Record review of a Medicare 5 day/ Modification of Discharge Return Anticipated MDS (Minimum Data Set) reference dated 2/4/25 revealed Resident #1's Brief Interview for Mental Status (BIMS) score was undetermined, and the resident required substantial/maximal assistance for eating and was dependent on staff for transferring. Record review of Resident #1's physician's orders sheet revealed orders dated 1/30/25 for Midodrine Hydrochloric Acid Oral Tablet 5 mg (Midodrine HCl) directions: Give one tablet via Percutaneous Endoscopic Gastrostomy (PEG) Tube every eight (8) hours for Hypotension (Low Blood Pressure) and Vital Signs every 8 hours, 2/7/25 Midodrine HCl Oral Tablet 5 mg (Midodrine HCl) directions: Give 1 tablet via PEG-Tube every 8 hours for hypotension (stopped on 2/10/25) and 2/10/25 Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) directions: Give 1 tablet via PEG-Tube every 8 hours as needed for hypotension for systolic (the top number of a blood pressure reading) less than 100. Review of Nursing Notes revealed on 2/9/25 at 2:24 PM [Resident #1] was noted with High Blood Pressure (B/P) during my shift, resident does not have any hypertension medication, patient had Midodrine scheduled which was not administered. I explained to the son who was in the room that I will contact the Doctor to get an order for hypertension medication, Son verbalizes been scared to Mom's B/P went low with BP medication. I contacted Dr and explained concerns and allergies and also suggested as needed (PRN) medication. Doctor ordered Lisinopril 2.5 mg daily. Son explained about order, medication, dose and time and he verbalized to be agreed. Record review of The Electronic Medication Administration Record and Treatment Administration Records for January and February 2025 revealed Midodrine 5 mg was administered on 1/31/25 at 6:00 AM the recorded B/P was 138/ 71, on 1/31/25 at 2:00 PM the recorded B/P was 167/72, on 1/31/25 at 10:00 PM the recorded B/P was 131/ 60, on 2/1/25 at 2:00 PM the recorded B/P was 143/ 63, on 2/2/25 at 2:00 PM the recorded B/P was 138/65, on 2/7/25 at 2:00 PM the recorded B/P was 136/79, on 2/7/25 at 10:00 PM the recorded B/P was 158/84 and on 2/8/25 at 2:00 PM the recorded B/P was 136/72. Interview on 2/25/25 at 2:20 PM, the Director of Nursing (DON) was asked when nursing staff are required to hold Midodrine if there are no parameters in the order. The DON stated: We practice not to have parameter as standard orders for medications affecting the blood pressure. If a parameter is set that is per physician's order. Our standard is to check residents blood pressure every 8 hours. We also have a reference booklet available to nursing staff if they have any questions about medications. It is located on their laptop. When there is no parameter, the physician did not order it. We have a system where medications are triple checked during the reconciliation process when residents are admitted . On 2/25/25 at 3:45 PM the Staff Pharmacist was asked about the proper administration including parameters of Midodrine; the Pharmacist stated: There is no guidance that says when Midodrine can or cannot be administered. The only contraindication is persistent and excessive supine hypertension. Routine orders for Midodrine don't usually have parameters. Record review of a policy provided titled, Preparation and General Guidelines, May 2022 revealed IIA2: Medication Administration -General Guidelines. Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals stored and labeled in accordance with professional principles, as evidenced by one out of three medication carts sampled was left unlocked and unattended with a medical ointment on top of the cart; and discrepancy with labeled orders and Electronic Medication Administration (EMAR). The findings included: On 2/25/25 at 8:43 AM during observation of medication administration conducted by Staff A, Licensed Practical Nurse (LPN) on the 2nd floor, Staff A, LPN stepped away from the medication cart to use the telephone at the nursing station, leaving the medication cart unlocked and a medical ointment on top of the cart. When Staff A, LPN returned to the cart the surveyor asked Staff A,LPN about the protocol for securing medication and storing ointments; Staff A,LPN replied: The cart should be locked when I walk away. The reason I left the cart unlocked when I walked away was because I could still see the cart. It is not okay to leave the cart unlocked. Ointments are kept in the treatment cart. I found this ointment and forgot to place it in the treatment cart. 2)On 2/25/25 at 9:12 AM a medication administration observation was conducted on the 2nd floor with Staff B, Registered Nurse (RN). Staff B, RN administered 15 ml (milliliters) of Lactulose solution as documented in the Electronic Medication Administration Record. However, the Lactulose bottle was labeled to administer 30 ml daily. Record review of a Policy titled, Medication Storage in the Facility dated April 2018 ID1: Storage of Medications revealed Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, record review and interview the facility failed to complete a self-administration of medication assessment for two residents (Resident #294 and Resident #648) out of ten residents sampled as evidenced by an observation of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at Resident # 294's and a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at Resident #648's. Both residents did not have a self-administration of medication assessment on file. There were 296 residents residing in the facility at the time of survey. On 05/06/2024 at 12:05 PM an observation was made of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at bedside of Resident #294. On 05/06/2024 at 12:05 PM Staff A, Registered Nurse (RN) stated: I am the nurse assigned to [Resident #294]. I am not aware of [Resident #294] being able to self-medicate or keep medications at the bedside and I will follow up with the supervisor. Staff A, RN removed medication from bedside. Record review of demographic sheet for Resident #294 revealed an admitted [DATE] with diagnosis that included Thrombocytopenic Purpura. Record review of Admission Minimum Data Set (MDS) dated [DATE], Section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Section GG for functional status revealed the resident set up/clean up assistance for eating/oral hygiene, substantial maximal assistance for toileting/ upper body dressing, and dependent for shower/bathe/transfer. Record review of activities of daily living deficit related weakness care plan initiated 4/20/2024 for Resident #294 revealed interventions included totally dependent for bathing, dressing and toileting with the assistance of one to two people. Record review of physician orders for Resident #294 on 05/06/2024 revealed no order found for Immune Support Bio-active silver hydrosol. Record review of assessments revealed no self-administration of medication on file. On 05/09/2024 at 12:22 PM Staff C, RN, stated: I am the charge nurse for this unit. For a resident to be allowed to self-medicate, a self-administration of medication assessment must be completed and an order from the doctor obtained. A self-administration of medication assessment was completed for [Resident #294] after the surveyor brought it to our attention that the medication was in the room. Observation on 05/06/2024 at 9:47 AM in Resident #648's room revealed a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at the resident's bedside. (photo evidence) On 05/06/2024 at 9:47 AM, Resident #648 stated: I use the ointment when the nurse isn't available and the drops to assist with falling asleep. On 05/06/2024 at 12:21 PM Staff B, RN stated: I am not aware of [Resident # 648] being allowed to self-medicate. Staff B, RN entered the room with the surveyor and Staff B, RN removed medications from the bedside and stated I will follow up with charge nurse and physician. Record review of demographic face sheet for Resident # 648 revealed an admitted [DATE] with diagnosis that included Aftercare following joint replacement surgery, need for assistance with personal care. Record review of the 5-day MDS dated [DATE] Section C revealed a BIMS score of 11, indicating moderate cognitive impairment. Section GG revealed Resident #648 was independent with eating, supervision or touching assistance for oral hygiene and partial moderate assistance for toileting. Record review of physician orders revealed an order dated 4/28/2024 for Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical) Apply to Whole Body topically four times a day for Joint Pain. No physician orders noted at that time for Valerian Extract. Review of the care plans documented self-care deficit and is at risk for further decline related to (r/t) Activity intolerance, Impaired mobility, Recent surgery to right knee, generalized weakness Care Plan initiated on 04/30/2024 revised on 04/30/2024. Interventions included ok for patient to self-administer Valerian Extract supplement, initiated on 05/06/2024. Record review of assessments revealed no self-administration of medication assessment on file. On 05/09/2024 at 11:22 AM Staff D, Licensed Practical Nurse (LPN) stated: I am the charge nurse of this unit. Residents can self-administer medications once a physician's order is obtained. No medications should be kept in the room without a physician's order. [Resident #648], brought this medication from the hospital and staff were not aware of medications being in the room. I spoke to the doctor and an order was obtained for [Resident # 648] to keep the herbal extract in room and the ointment was removed. On 05/09/2024 at 10:23 PM The Director of Nursing (DON) stated that any resident who wishes to self-administer medication, a self-administration assessment must be on file. Record review of Policy and Procedure entitled: Preparation and General Guidelines April 2018. IIA10: Self-Administration of Medications. Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.

Based on observation, record review and interview, the facility failed to develop and implement care plan interventions for two residents (Resident number 1, Resident number 2) out of three residents identified at risk for falls. Resident number 1 and Resident number 2 had falls that resulted in major injuries. The findings included: 1) Record review of the facility's MDS (Minimum Data Set) Comprehensive Assessment and Care Plan Policy and Procedure (effective 3/31/2022) documented the following: Policy-It is the policy to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of all residents will be completed in the format and in accordance with time frames; Procedure: 7) The facility will develop a comprehensive person-centered care plan for each resident in the nursing home facility that includes measurable objectives and timeframes to meet the resident's clinical, mental, psychosocial needs that are identified in the comprehensive assessment. Observation of Resident number 1 on 4/12/23 at 10:59 AM, revealed the resident was sitting up in a low bed with floor mats, tv on and the tube feeding machine was off. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 1 documented the resident was admitted to the facility on [DATE] with diagnoses to include unspecified displaced fracture of fourth cervical vertebra, subsequent encounter for fracture with routine healing, unspecified displaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, cognitive communication deficit, encounter for attention to gastrostomy, hemiplegia, anxiety disorder, major depressive disorder, mood disorder, dementia, insomnia, repeated falls, hypertension, glaucoma and parkinson's disease. The resident was discharged to the hospital on 3/27/2023 with a cervical spine fracture at C4 and C6 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident number 1 dated 1/16/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 12 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and total dependence with one person physical assist for bed mobility and impairment on one side for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 1 for March 2023 and April 2023 documented the following: Trazodone HCL oral tab (tablet) 50mg (milligrams) 0.5 tab via PEG (percutaneous endoscopic gastrostomy) tube HS (at night) for insomnia, Melatonin oral tab 5mg 1 tab via PEG tube HS for insomnia, Ramelteon oral tab 8mg (milligrams) 1 tab via PEG tube HS for insomnia, Plavix oral tab 75mg 1 tab via PEG tube in the evening for blood clots, Fall Precautions as care planned every shift for prevention of falls, Ensure fall precautions are in place as specified in the care plan (Start date 3/30/23), Floor mats every shift for safety (Start date 4/04/23), Low Bed every shift for safety (Start date 4/04/23) and Half Side Rail (1/2) every shift for safety precautions (Start date 4/04/23). Review of Resident number 1's Fall care plan dated 6/02/16 documented the resident was at risk for falls and fall related injuries related to history of falling, repeated falls, poor safety awareness, impaired mobility, tendency to over-estimate limits and diagnosis of parkinson's disease, dementia, difficulty in walking, unsteadiness on feet and Glaucoma; Goal: Resident will not sustain serious injury related to fall through the review date; Interventions: Bed in the lowest position at all times. Resident number 1 also had the following care plans: ADLs (activities of daily living), Communication, Impaired Cognitive Function/Dementia, Cardiac, Nutrition, Impaired Mobility, Insomnia/Restlessness, Antidepressant, Mood Problem, Parkinson's Disease and Glaucoma. Interview with Staff A, CNA (Certified Nursing Assistant) on 4/12/23 at 11:03 AM. She stated, Everyday she try to get out of the bed. I couldn't get to her in time. I had to pass all the trays by myself on that day and a lot of patients were waiting on me to get them showered and dressed. I was trying to get her ready to put her in the chair. I was brushing her teeth and I went to rinse out the tooth brush. The bed rails was half way up. While I was washing the tooth brush, I saw her foot on the floor and I tried to catch her but my foot got caught under the table and I almost fell myself. Since I couldn't catch her she fell out of the bed. When that happened, I went to call the nurse. She had blood under her head because she hit her head on the table. The nurse came and called everybody to assess her. I was suspended for 5 or 6 days. Interview with Staff B, Registered Nurse (RN), Unit Manager on 4/12/23 at 11:16 AM. She stated, When it happened the cna immediately called out for the nurse and she went in there. The nurse went to the room and the cna came to get me while the nurse was with the resident. The resident was on the floor applying pressure to the head where blood was coming from. They said call [emergency services] I rushed to the nurses station to call PAT [Patient Assessment Team] and [emergency services]. Doctors came into assess the patient, we had two doctors here on that day. We sent her out immediately via [emergency services]. All of our residents were on fall precaution. Floor mats were not used before, this is a new intervention. The low bed was not in effect when the fall, new intervention. We notified RISK and received in-service when she came back. She left on the 3/28 and returned on 4/07. When the resident fell and we found out she had a fracture, she was suspended. The resident had a cervical fracture due to the fall. She could have reported to the nurse, asked for assistance and place her in a supervised area. Safety is always first was emphasized in the in-service. Interview with the Director of Nursing (DON) on 4/12/23 at 12:10 PM. She stated, On 3/27/23, at 10:13 AM, resident had a witness fall in her room, The nursing assistant that was in the room at the time. According to the nursing staff she was providing ADL care and she stepped away to wash out a toothbrush. While in bathroom, she saw the resident trying to get out of bed. The nursing assistant ran to the resident but she tripped on the bedside table, her leg got stuck and she fell herself and that's when the patient fell and did not get to her on time. The resident was transferred out to Mt. [NAME]. She had a cervical spine fracture. She had a fall care plan. She needed to have the bed in the lowest position, according to cna statement it was. Floor mats were added after the fall. Before she had bed in a lowest position but now the bed is 8 inches off the floor, almost touching the floor. The cna was placed on administrative leave during our investigation, interview by risk management. Gave us her statement, she tripped on the bedside table. At the time the resident could not be left unattended. The bed side rails was down and she usually puts it back up when she steps away. If a staff member identify a patient is trying to get up or restless, not to walk away or get some assistance. She had already identified the patient was trying to get up. We determined that it was not intentional neglect that's why we didn't submit to the nurse board. Interview with the Director of Risk Management on 4/12/23 at 1:08 PM. She stated, On 3/27/23, I was informed the pt had a witnessed fall during ADL care. While providing care to the resident, she left the resident to go wash the toothbrush and when she went back the pt was attempting to get up by the time she trying to reaching the resident her foot got stuck by the bedside table and she almost fell . The resident had a fall. The cna called the nurse, the nurse came into the room and observed the resident. The nurse called the PAT (Patient Assessment Team) with two physicians, nurse manager, cna they assessed the patient and gave order to transfer her to the hospital. She had an injury and she was bleeding. We found out later a fracture of the cervical. Automatically the cna was on administrative leave until the investigation was completed. The Immediate Report and 5 day report substantiated neglect. The patient was attempting to get out of bed, she usually will keep the quarter side rail up and she didn't. I didn't report it to the board because she had been here for a while, she was not malicious and very remorseful and she did not put the side rails up. 2) Observation of Resident number 2 on 4/12/23 at 11:36 AM, revealed the resident was sitting in a wheelchair wearing glasses in the 5th floor dining room holding a toy cat. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 2 documented the resident was admitted to the facility on [DATE] with diagnoses to include dementia, laceration of muscle and tendon of head, subsequent encounter, adult failure to thrive, fracture of sacrum, subsequent encounter for fracture with routine healing, hypertension, muscle weakness and unspecified abnormalities of gait and mobility. The resident was discharged to the hospital on 2/02/2023 with a hematoma to the head and a fracture to the sacrum and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Admission Assessment for Resident number 2 dated 1/14/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating cognitive impairment. The resident required limited to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and no impairments for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 2 for February 2023 documented the following: Half Side Rail (1/2) every shift for to use during care and mobility (Start 3/05/23) and Fall precautions as care planned every shift for prevention (Start 2/09/23). Review of Resident number 2's Fall care plan dated 1/11/23 documented the resident had history of falls and remains at risk for further incidents related to gait/balance problems, needs assistance with daily activities, needs assistance with ADLs, diagnosis of dementia; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Bed in low position (initiated 4/12/23) and call light within reach (initiated 3/14/23); Make frequent rounds when resident is in her room (initiated 3/14/23). Resident number 2 also had the following care plans: ADLs (activities of daily living), Dementia and Impaired Cognitive Function. Interview with the Director of Nursing (DON) on 4/12/23 at 12:22 PM. She stated, On 2/02/23, around 4 in the morning, the patient found on the floor in the bathroom doorway. Left side hematoma noted and bleeding. At the time did not complain of pain but was transferred out to hospital for further evaluation. She returned with a sacral fracture. She was care planned for falls. She did not require a lot of assistance. She was here for rehab to get better and go back home. Interview with Staff C, Licensed Practical Nurse (LPN) and the DON on 4/12/23 at 12:37 PM via telephone. She revealed that she was not involved in the incident. She let one of the nurses' use her sign-in ID to document the incident. Interview with the Director of Risk Management on 4/12/23 at 1:19 PM. She stated, On 2/02/23, she fell and had a hematoma. The doctor decided to send her out because she hit her head. No one was in the room with her when she fell . She had a fracture to the sacrum.

Based on observation, record review and interview, the facility failed to provide adequate supervision to ensure the safety of vulnerable residents and to prevent falls that resulted in major injuries for two (Resident #1, Resident #2) out of three residents reviewed for falls. Resident #1 sustained a cervical spine fracture at C4 and C6 (cervical) and Resident number 2 sustained a hematoma to the head and a fracture to the sacrum. This practice has the potential to affect all 274 residents present in the facility at the time of the survey. The findings included: 1) Record review of the facility's Fall Prevention Policy and Procedure (effective December 1990, revised April 2021) documented the following: Procedures-1) When a resident is admitted to the facility: a) The nurse will complete a Fall Risk Screening Tool as part of the resident's admission evaluation; b) The Fall Risk Screening tool will determine if the resident is at a High, Moderate or Low Risk for Falls; c) Interventions and medication management will be planned implemented and documented according to each resident's risk level and individual needs; e) The residents fall risk status will be communicated to all staff members caring for the resident through the resident's care plan. Observation of Resident number 1 on 4/12/23 at 10:59 AM, revealed the resident was sitting up in a low bed with floor mats, tv on and the tube feeding machine was off. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 1 documented the resident was admitted to the facility on [DATE] with diagnoses to include unspecified displaced fracture of fourth cervical vertebra, subsequent encounter for fracture with routine healing, unspecified displaced fracture of sixth cervical vertebra, subsequent encounter for fracture with routine healing, cognitive communication deficit, encounter for attention to gastrostomy, hemiplegia, anxiety disorder, major depressive disorder, mood disorder, dementia, insomnia, repeated falls, hypertension, glaucoma and parkinson's disease. The resident was discharged to the hospital on 3/27/2023 with a cervical spine fracture at C4 and C6 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident number 1 dated 1/16/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 12 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and total dependence with one person physical assist for bed mobility and impairment on one side for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 1 for March 2023 and April 2023 documented the following: Trazodone HCL oral tab (tablet) 50mg (milligrams) 0.5 tab via PEG (percutaneous endoscopic gastrostomy) tube HS (at night) for insomnia, Melatonin oral tab 5mg 1 tab via PEG tube HS for insomnia, Ramelteon oral tab 8mg 1 tab via PEG tube HS for insomnia, Plavix oral tab 75mg 1 tab via PEG tube in the evening for blood clots, Fall Precautions as care planned every shift for prevention of falls, Ensure fall precautions are in place as specified in the care plan (Start date 3/30/23), Floor mats every shift for safety (Start date 4/04/23), Low Bed every shift for safety (Start date 4/04/23) and Half Side Rail (1/2) every shift for safety precautions (Start date 4/04/23). Review of Resident number 1's Fall care plan dated 6/02/16 documented the resident was at risk for falls and fall related injuries related to history of falling, repeated falls, poor safety awareness, impaired mobility, tendency to over-estimate limits and diagnosis of parkinson's disease, dementia, difficulty in walking, unsteadiness on feet and Glaucoma; Goal: Resident will not sustain serious injury related to fall through the review date; Interventions: Bed in the lowest position at all times. Resident number 1 also had the following care plans: ADLs (activities of daily living), Communication, Impaired Cognitive Function/Dementia, Cardiac, Nutrition, Impaired Mobility, Insomnia/Restlessness, Antidepressant, Mood Problem, Parkinson's Disease and Glaucoma. Review of the incidents/falls log dated February 2023-April 2023, documented that Resident number 1 had a fall on 3/27/23. Review of the fall note progress notes for Resident number 1 documented the following: Dated 3/27/23 11:01-Fall Note: 10:13 AM Witnessed fall in patient room by CNA. 10:15 AM PAT [Patient Assessment Team] TEAM and 911 called. Upon arrival patient found on floor. Noted head injury with bleeding. Immediate first aide applied cervical stabilization and pressure to head injury. Vital signs taken. Head to toe palpation done no sign of pain response upon exam. 10:20 AM PAT Team arrived. Released care to PAT team. Patients primary physician is part of the PAT team. No notification needed via telephone. 10:24 AM Patient moved to sitting chair from floor after PAT Team evaluation. 10:25 AM Pressure bandage wrap applied to the patients head. Blood sugar level 111 obtained. Vital signs taken. 10:26 AM 911 arrived. Report given to emergency team by lead PAT team member. 10:27 AM Patient ambulated to stretcher. 10:28 AM Patient transported to ER [Mount S ]. 10:35 AM Patient relative called and notified of patients fall and transport to ER. Review of the five day federal report for Resident number 1 documented the following: While the CNA was providing care to the resident, the resident remained in bed; then the CNA went to go wash the resident's toothbrush in the bathroom. Upon returning to the bedside, the CNA observed the resident was attempting to get out of bed and she fell . The staff was put on administrative leave. Interview with Staff A, CNA (Certified Nursing Assistant) on 4/12/23 at 11:03 AM. She stated, Everyday she try to get out of the bed. I couldn't get to her in time. I had to pass all the trays by myself on that day and a lot of patients were waiting on me to get them showered and dressed. I was trying to get her ready to put her in the chair. I was brushing her teeth and I went to rinse out the tooth brush. The bed rails was half way up. While I was washing the tooth brush, I saw her foot on the floor and I tried to catch her but my foot got caught under the table and I almost fell myself. Since I couldn't catch her she fell out of the bed. When that happened, I went to call the nurse. She had blood under her head because she hit her head on the table. The nurse came and called everybody to assess her. I was suspended for 5 or 6 days. Interview with Staff B, Registered Nurse (RN), Unit Manager on 4/12/23 at 11:16 AM. She stated, When it happened the cna immediately called out for the nurse and she went in there. The nurse went to the room and the cna came to get me while the nurse was with the resident. The resident was on the floor applying pressure to the head where blood was coming from. They said call [emergency services] I rushed to the nurses station to call [P.A.T.] and [emergency services]. Doctors came into assess the patient, we had two doctors here on that day. We sent her out immediately via [emergency services]. All of our residents were on fall precaution. Floor mats were not used before, this is a new intervention. The low bed was not in effect when the fall, new intervention. We notified RISK and received in-service when she came back. She left on the 3/28 and returned on 4/07. When the resident fell and we found out she had a fracture, she was suspended. The resident had a cervical fracture due to the fall. She could have reported to the nurse, asked for assistance and place her in a supervised area. Safety is always first was emphasized in the in-service. Interview with the Director of Nursing (DON) on 4/12/23 at 12:10 PM. She stated, On 3/27/23, at 10:13 AM, resident had a witness fall in her room, The nursing assistant that was in the room at the time. According to the nursing staff she was providing ADL care and she stepped away to wash out a toothbrush. While in bathroom, she saw the resident trying to get out of bed. The nursing assistant ran to the resident but she tripped on the bedside table, her leg got stuck and she fell herself and that's when the patient fell and did not get to her on time. The resident was transferred out to Mt. [NAME]. She had a cervical spine fracture. She had a fall care plan. She needed to have the bed in the lowest position, according to cna statement it was. Floor mats were added after the fall. Before she had bed in a lowest position but now the bed is 8 inches off the floor, almost touching the floor. The cna was placed on administrative leave during our investigation, interview by risk management. Gave us her statement, she tripped on the bedside table. At the time the resident could not be left unattended. The bed side rails was down and she usually puts it back up when she steps away. If a staff member identify a patient is trying to get up or restless, not to walk away or get some assistance. She had already identified the patient was trying to get up. We determined that it was not intentional neglect that's why we didn't submit to the nurse board. Interview with the Director of Risk Management on 4/12/23 at 1:08 PM. She stated, On 3/27/23, I was informed the pt had a witnessed fall during ADL care. While providing care to the resident, she left the resident to go wash the toothbrush and when she went back the pt was attempting to get up by the time she trying to reaching the resident her foot got stuck by the bedside table and she almost fell . The resident had a fall. The cna called the nurse, the nurse came into the room and observed the resident. The nurse called the PAT (Patient Assessment Team) with two physicians, nurse manager, cna they assessed the patient and gave order to transfer her to the hospital. She had an injury and she was bleeding. We found out later a fracture of the cervical. Automatically the cna was on administrative leave until the investigation was completed. The Immediate Report and 5 day report substantiated neglect. The patient was attempting to get out of bed, she usually will keep the quarter side rail up and she didn't. I didn't report it to the board because she had been here for a while, she was not malicious and very remorseful and she did not put the side rails up. 2) Observation of Resident number 2 on 4/12/23 at 11:36 AM, revealed the resident was sitting in a wheelchair wearing glasses in the 5th floor dining room holding a toy cat. Attempted to interview the resident but she did not participate in the interview. Review of the Demographic Face Sheet for Resident number 2 documented the resident was admitted to the facility on [DATE] with diagnoses to include dementia, laceration of muscle and tendon of head, subsequent encounter, adult failure to thrive, fracture of sacrum, subsequent encounter for fracture with routine healing, hypertension, muscle weakness and unspecified abnormalities of gait and mobility. The resident was discharged to the hospital on 2/02/2023 with a hematoma to the head and a fracture to the sacrum and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Admission Assessment for Resident number 2 dated 1/14/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 07 out of 15 indicating cognitive impairment. The resident required limited to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and no impairments for the upper and lower extremities. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident number 2 for February 2023 documented the following: Half Side Rail (1/2) every shift for to use during care and mobility (Start 3/05/23) and Fall precautions as care planned every shift for prevention (Start 2/09/23). Review of Resident number 2's Fall care plan dated 1/11/23 documented the resident had history of falls and remains at risk for further incidents related to gait/balance problems, needs assistance with daily activities, needs assistance with ADLs, diagnosis of dementia; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Bed in low position (initiated 4/12/23) and call light within reach (initiated 3/14/23); Make frequent rounds when resident is in her room (initiated 3/14/23). Resident number 2 also had the following care plans: ADLs (activities of daily living), Dementia and Impaired Cognitive Function. Review of the incidents/falls log dated February 2023-April 2023, documented that Resident number 2 had a fall on 3/27/23. Review of the incidents/falls list dated February 2023-March 2023, documented that Resident number 2 had a fall on 2/02/23. Review of the abuse log dated February 2023-April 2023, documented that Resident number 2 was on the abuse log for neglect and the allegation was unsubstantiated. Review of the nursing note progress notes for Resident number 2 documented the following: Dated 2/02/23 04:30- 03:50 While on unit resident was heard moaning, assigned nurse went to check on her, she was found lying on her back in the doorway of the bathroom in a small pool of blood under her head. Resident was carefully put back to bed v/s and assessment completed, hematoma noted to the left parietal area, not bleeding presently, [emergency service] called, transfer order obtained from MD. [Emergency service] arrived at 04:05, left for MSMC at 04:08. Resident remained awake and alert throughout. She stated she was going to the bathroom without assistance. Message was left for residents son, residents son to call the unit. Review of the fall note progress notes for Resident number 2 documented the following: Dated 2/02/23 04:40-Fall Note: Patient found on the floor of bathroom doorway. On assessment blood was noted to be coming from head. The patient noted to have left sided hematoma. All extremities within range of motion. The resident was assisted back to bed. The patient denied pain. The nursing supervisor was on the unit at this time. The patient was transferred to [Mt. S Hospital] via emergency services; as per primary physician and made aware of patient condition. Emergency services were called and arrived to the unit. The patient's son was called, a voicemail was left for return call back. Review of the five day federal report for Resident number 2 documented the following: Around 11:30 AM, the Nurse Supervisor reported to Risk Management that resident sustained a fracture from a fall. Once the resident returned to the facility, the resident's fall care plan was reviewed and updated with new interventions and they will be followed. The resident will be closely monitored while her safety and comfort measures will be maintained. Interview with the Director of Nursing (DON) on 4/12/23 at 12:22 PM. She stated, On 2/02/23, around 4 in the morning, the patient found on the floor in the bathroom doorway. Left side hematoma noted and bleeding. At the time did not complain of pain but was transferred out to hospital for further evaluation. She returned with a sacral fracture. She was care planned for falls. She did not require a lot of assistance. She was here for rehab to get better and go back home. Interview with Staff C, Licensed Practical Nurse (LPN) and the DON on 4/12/23 at 12:37 PM via telephone. She revealed that she was not involved in the incident. She let one of the nurses' use her sign-in ID [identification] to document the incident. Interview with the Director of Risk Management on 4/12/23 at 1:19 PM. She stated, On 2/02/23, she fell and had a hematoma. The doctor decided to send her out because she hit her head. No one was in the room with her when she fell . She had a fracture to the sacrum.

Based on observations, interviews, and record review, the facility failed to provide assistance during dining observation for 1 (Resident #293) of 6 residents reviewed for nutrition. The findings included: In an observation conducted on 12/12/22 at 1:00 PM, Resident #293 was noted in her room with the lunch tray. The lunch tray was observed to be 100% untouched, and no staff was noted in the room. Continued observation at 1:25 PM showed no staff in the room assisting Resident #293 with her lunch meal. In an observation conducted on 12/13/22 at 8:03 AM, Resident #293 was noted in her room with the breakfast tray in front of her. The tray was set up, and some of the food was cut into smaller pieces, but no staff was noted in the room. It was noted that 50 % of the [brand] nutritional supplement was 50% consumed. The food on the tray was noted to be 100% untouched. At 8:17 AM, showed Staff in the room standing over Resident #293, asking her if she wanted to eat. At 8:18 AM, Staff noted walking out of the room, and the food on the tray was still 100% untouched. Continued observation showed that at 8:28 AM, the tray was still 100% untouched with no staff assistance in the room. (Photographic evidence obtained) A chart review showed that Resident #293 was admitted on [DATE] with diagnoses of dysphagia, muscle weakness, and acute kidney failure. The Minimum Data Set (MDS) dated [DATE] showed that Resident #293 had a Brief Interview of Mental Status (BIMS) score of 03, which is severely cognitively impaired. It further showed that under eating in Section G, Resident #293 needs extensive assistance with one person assists during dining. A Physician order noted for a Mechanical Soft/Ground texture, Thin Fluids consistency, for Diet/Nutrition dated 12/01/22, and at risk for Malnutrition dated 11/14/22. A Mini Nutritional assessment dated [DATE] showed that Resident #293 is malnourished. The Nutrition Risk assessment dated [DATE] showed that Resident #293 had a weight loss before her admission to the facility. It further showed that Resident #293 had a 50% intake of meals with supervision to total assistance. Resident #293's fluid intake did not meet her estimated needs, and her food intake met 60% of her estimated needs. A review of the Dietary note dated 12/09/22 showed Nursing reports poor appetite x (times)1 week and that Resident #293 is with 100% intake of supplements and 0% intake at meals. The Care plan dated 11/29/22 showed that Resident #293 has the potential/actual nutritional problems related to Chewing/swallowing difficulty and is dependent on eating and drinking. In an interview conducted on 12/14/22 at 5:20 PM with Staff D, Certified Nursing Assistant, was asked if Resident #293 needs help with her meals, Staff D stated, yes, she is a Feeder. When asked by surveyor what that meant, Staff D reported that the resident needed total assistance in the room with all her meals. In an interview conducted on 12/14/22 at 5:30 PM, Resident #293's daughter stated that Staff told her that her mom was not eating at all. She further said that when she comes to see her mom, the Staff say that they will come back to help her with her meals, but they never return to the room. In an interview with the facility ' s Administrator on 12/15/22 at 11:20 AM, he was told of the findings. Class III

Based on observations, interviews, and record review, the facility failed to provide the correct food consistencies for the ordered Pureed diets during dining observations and the second tour of the main kitchen. This has the potential to affect 52 residents residing in the facility on a Pureed diet. The findings included: A review of the Nation Dysphagia Diet Pureed Nutrition Therapy dated September 24, 2019, which Staff E, Registered Dietitian provided, showed the following: Pureed diet is indicated for the resident who has difficulty chewing or swallowing food items and benefits from stricter modifications of food textures to provide foods that can be successfully and safely swallowed. This diet consists of foods that are easy to swallow because they are pureed, smooth, and lump-free, not firm or sticky_ Foods do not require any chewing and may be prescribed due to several medical conditions. In an observation conducted on 12/12/22 at 1:00 PM, Resident #751 was noted in her room with her lunch tray. Closer observation showed the following: a lunch plate of pureed white rice, pureed red cabbage, and 2-inch pieces of beef stew cubes that did not have the same consistency as the pureed rice or the pureed red cabbage. Continued observation showed Resident #751 struggled to cut through the cubed beef stew. (Photographic evidence obtained). A chart review showed that Resident #751 was admitted on [DATE] with a diet order of No Added Salt Pureed texture diet, which was dated 12/12/22. In an observation conducted on 12/14/22 at 11:25 AM, during the lunch meal tray line, two plates of Pureed diet were observed with the following: pureed yellow squash, pureed white rice, and a sizeable, molded piece of seared tilapia (fish) that did not have the same consistency as the white rice or the yellow squash. (Photographic evidence obtained). In this observation, Staff A, Execute Chef, and Staff E, a Registered Dietitian, in the presence of two state surveyors, were asked to take a spoon and cut through the consistency of yellow squash, white rice, and tilapia. Continued observation showed that Staff A could smoothly cut through the white rice and the yellow squash. When attempting to cut through the tilapia, he used more force to cut through, and the consistency of the tilapia was observed with small lumpy pieces. Staff E was then asked to try and cut through the tilapia, yellow squash, and white rice. She acknowledged that more force was used to cut through the fish than the yellow squash or the white rice. Staff E also stated that while cutting the foods, the feeling of consistency was different between the yellow squash and the white rice in comparison to the tilapia. (Photographic evidence obtained). In an interview conducted on 12/14/22 at 11:40 AM with Staff A, the Executive Chef stated that he pureed the tilapia using a blender and used a thickener to mold the fish into the shape that was observed. He then used round tubes to shape them into a firmer shape, so they have a nice appearance on the plate. In an interview conducted on 12/14/22 at 12:07 PM with Staff B and Staff C, Speech Language Pathologists, they stated that pureed diet is completely blended with no chewing involved. When asked if there are several pureed diet levels, they said no. They further stated that they had yet to observe the cooking process in the kitchen for the pureed diet consistencies. According to Staff B and Staff C, the pureed diet should not have lumps or pieces. In an interview conducted on 12/14/22 at 12:20 PM Staff E, Registered Dietitian, acknowledged all findings. She further stated that 52 residents in the facility are on a pureed diet.

Based on record review and interview, the facility failed to maintain an accurate record for one (Resident #1) out of three residents sampled for falls. A report was filed by the facility that the resident was on one-to-one (1:1) supervision but the resident was not. There was a total of 300 residents present in the facility at the time of this survey. The findings included: Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] with a fracture of head of right femur and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #1 dated 7/25/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment. The resident required extensive assistance with one-person physical assist for ADLs (Activities of Daily Living) and extensive assistance with two +(plus) persons physical assist for transfers. No alarms (bed, chair, motion sensor) were used. Review of Resident #1's Physician' s Order Sheets (POS)for August 2022 through November 2022 documented the following orders: 1:1 Sitter/Monitoring around the clock every shift (Start 2/13/22; End 7/08/22); Transfer out to [local hospital] ER for evaluation Dx (diagnosis): Head Trauma/Right Hip Pain (Revision 8/31/22); Resident needs continuous supervision, may attend the busy bee program during the day from 0930 AM to 9:30 PM (Revision 9/04/22); Fall precautions as care planned every shift for prevention of falls, ensure fall precautions are in place as specified in the care plan (Start 9/05/22); 1:1 monitoring during hours of sleep, resident may be monitored with the [fall system] sensor when 1 to 1 is not available (Start 9/08/22), May use [alert system] Predictive Fall Prevention and Close Supervision (1:1 sitter, [fall alert system] device or Busy Bee Program) (Start 10/11/22). Review of the Treatment Administration Records (TAR) for Resident #1 for August 2022 through November 2022 documented the following: Fall precautions every shift (Start 1/20/22); Out of bed with assistance, only contact guard and rolling walker every shift (Start 1/20/22); May use alarm Predictive Fall Prevention every shift for prevention of falls; Ensure fall precautions are place as specified in the care plan (Start 8/23/22) and Resident needs continuous supervision, may attend the Busy Bee Program during the day from 0930 AM to 9:30 PM every shift for safety (Start 8/23/22). The TAR on 8/29/22 documented the alarm sensor was in place and working for day and night. Review of Resident #1's Fall care plan dated 1/23/22 documented the resident was at risk for falls related to incontinence, history of falls, unaware of safety needs daily use of antidepressant medication, unable to follow instructions and impulsive to get out of bed on his own without calling for assistance; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Close supervision (1:1 sitter, [fall alert system] device or Busy Bee Program) every shift; Document methods of supervision used during the shift (date initiated 10/31/22); Bed in lowest position (date initiated 10/11/22; revision 10/11/22); Call light within easy reach (date initiated 1/23/22); Encourage/educate resident to use call-light for assistance (date initiated 9/23/22). Resident #1 also had the following care plans: ADLs, Impaired Cognitive Function, Diabetes Mellitus, Antidepressant, Major Depressive Disorder, [CONDITION(S)] Meds, Anxiety and [CONDITION(S)]. Review of the falls list dated August 2022 to November 2022, documented that Resident #1 had a fall on 8/30/22 with the resident found on the floor and sustained a bruise. Review of the Adverse Incidents Log dated August 2022 to November 2022, documented an incident with Resident #1 occurred on 8/30/22, the date of 15-day report filed on 9/13/22 and the findings were substantiated. Review of the immediate federal report for Resident #1 documented the following: Date/Time of Incident: 8/30/2022 0031; Type of Incident: Neglect; Outcome: Fracture or dislocation of bones or joints; Description of Incident: On 08/30/22, resident was found on the floor by a CNA. He was assisted from floor to bed. he was assessed and no injuries noted but he complained of hip pain. Nurse Practitioner was notified, and order was given to transfer resident to the hospital for further evaluations. Upon investigation, it was found that the resident needed a 1 to 1 sitter due to high risk for fall. While the continuous monitoring was in the place, the CNA stepped away and upon her return back to the room, the resident was found on the floor stating, I was going to go the bathroom, lost my balance and fell . Review of the five-day federal report for Resident #1 documented the following: Investigative Findings: The hospital called the facility to report that resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident is substantiated.; Allegation Substantiated: Yes; Correct Actions/Actions to be taken: The facility educated the staff on the One to One, Abuse, Neglect and Exploitation. Review of the progress notes for Resident #1 documented the following: Dated 8/30/22 00:00-Fall Note: Resident was found on floor by CNA. Observed resident on his right side by bathroom entrance. Resident stated he was trying to go to the bathroom and lost his balance. Resident hit top of head. No visible injuries noted. Resident c/o (complained of ) right hip pain. Supervisor notified. ARNP (Advanced Registered Nurse Practitioner) notified and next of kin notified; Dated 8/30/22 00:05-Fall Note: Staff nurse call to report fall, upon arrival resident in bed stated he was going to bathroom and lost his balance and fell , stated he hit his head, denies loss of consciousness, also c/o right hip pain with movement between 3-5 scale on 1-10, resident stated he didn't use call light because he can do it on his own. ARNP on duty made aware of findings, order received to transfer to local hospital ER (emergency room ) for further evaluation and CT (computerized tomography) scan. Same was done resident was transfer with rescue, family made aware; Dated 8/30/22 05:23-Transfer to hospital and Dated 8/30/22 09:53-Call placed to the hospital report received the ER nurse she said that resident is admitted for right head femur fracture. Review of the Hips Bilateral 2 Views Pelvis X-Rays for Resident #1 dated 8/30/22 documented the findings/impression were: Complete right femoral neck fracture with mild displacement and angulation. Review of the Fall Risk Assessment Form for Resident #1 dated 6/01/22 documented the resident was High Risk for Falling with a score of 75.0. On 11/17/22 at 12:26 PM, the Director of Risk Management stated, He got up to go to the bathroom and he fell in his room. We transferred him to the hospital and the hospital called and told us it was a fracture. It was substantiated as neglect and an adverse incident. The patient was on 1:1 and the CNA (Certified Nursing Assistant) left the room to answer another call and when she got back in the room the patient was on the floor .The resident said she wasn't gone that long but that didn't matter. She should have called someone to come and assist her. He is still on 1:1 and in the Busy Bee Program 9:00 AM to 9:30 PM. During an interview on 11/17/22 at 1:00 PM, the Director of Nursing (DON) stated, On 8/30/22, the CNA found him on the floor. He stated he was going to the bathroom and lost his balance. He hit his head and complained of right hip pain. The ARNP ordered to transfer him to the hospital. He was on 1:1 at night and during the day he goes to the Busy Bee Program. The CNA alleges she was him, heard another resident's call light go off and she stepped away for 5 minutes and when she came back the resident was on the floor. We didn't find out about the fracture until the next day on 8/31/22, x-rays were done at the hospital . The Busy Bee Program has been existence since October 2021 for 1 year. He started on the sensor on 8/04/22. On 11/17/22 at 2:27 PM, during an interview via telephone with the Staff A, Certified Nursing Assistant (CNA) in the presence of the DON, Staff A stated, I was working 11-7. I was assigned to 8 patients. I was taking blood pressure for another patient, and I heard a noise in [Resident #1's] room. I went to his room, and I saw him on the floor. I called the nurse. I was not on 1:1 with the resident. The nurse called the supervisor, and the supervisor came and then they took him to the hospital. I know if I am on 1:1 with a patient, I do not leave that patient for nothing. I don't remember receiving in-service on 1:1 supervision and following care plans from the DON and Risk Manager. Subsequent interview and record review with the DON on 11/17/22 at 3:32 PM concerning the Staff CNA Assignments on 8/30/22 documented the CAN (Staff A) was assigned 8 residents on the shift. The DON revealed that the Staff Assignment for Staff A, CNA was 8 residents and not 1:1.

Based on observation, record review and interview, the facility failed to implement a written care plan related to falls for one resident (Resident #1) out of three residents reviewed for falls. Resident #1 had a fall that resulted in a major injury. This practice has the potential to affect all 300 residents present in the facility at the time of the survey. The findings included: Observation of Resident #1 on 11/12/22 at 9:20 AM, revealed Resident #1 was sitting in a wheelchair in the third-floor activity room in the facility's Busy Bee Program and his left leg was bandaged. Attempted to interview the resident but he did not participate in the interview. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] with a fracture of head of right femur and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #1 dated 7/25/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment. The resident required extensive assistance with one-person physical assist for ADLs (Activities of Daily Living) and extensive assistance with two+ persons physical assist for transfers. No alarms (bed, chair, motion sensor) were used. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident #1 for August 2022 through November 2022 documented the resident was receiving insulin medication and antidepressant medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Also documented were the following orders: 1:1 Sitter/Monitoring around the clock every shift (Start 2/13/22; End 7/08/22); Transfer out to[Local Hospital] ER (emergency room ) for evaluation Dx: Head Trauma/Right Hip Pain (Revision 8/31/22); Resident needs continuous supervision, may attend the busy Bee Program during the day from 0930 AM to 9:30 PM (Revision 9/04/22); Fall precautions as care planned every shift for prevention of falls, ensure fall precautions are in place as specified in the care plan (Start 9/05/22); 1:1 Monitoring during hours of sleep, resident may be monitored with the [] sensor when 1 to 1 is not available (Start 9/08/22), May use [ fall alert brand] predictive fall prevention alert system and close supervision (1 to 1 sitter, []Alert Device or Busy Bee Program) (Start 10/11/22). Review of the Treatment Administration Records (TAR) for Resident #1 for August 2022 through November 2022 documented the following: Fall precautions every shift (Start 1/20/22); Out of bed with assistance, only contact guard and rolling walker every shift (Start 1/20/22); May use alarm Predictive Fall Prevention every shift for prevention of falls; Ensure fall precautions are place as specified in the care plan (Start 8/23/22) and Resident needs continuous supervision, may attend the Busy Bee Program during the day from 09:30 AM to 9:30 PM every shift for safety (Start 8/23/22). The TAR on 8/29/22 documented the alarm sensor was in place and working for day and night. Review of Resident #1's fall care plan dated 1/23/22 documented the resident was at risk for falls related to incontinence, history of falls, unaware of safety needs daily use of Antidepressant medication, unable to follow instructions and impulsive to get out of bed on his own without calling for assistance; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Close supervision (1:1 sitter, []Alert Device or Busy Bee Program) every shift; document methods of supervision used during the shift (date initiated 10/31/22); bed in lowest position (date initiated 10/11/22; revision 10/11/22); call light within easy reach (date initiated 1/23/22); encourage/educate resident to use call-light for assistance (date initiated 9/23/22). Resident #1 also had the following care plans: ADLs, Impaired Cognitive Function, Diabetes Mellitus, Antidepressant, Major Depressive Disorder, [CONDITION(S)] Meds, Anxiety and [CONDITION(S)]. On 11/17/22 at 12:26 PM, the Director of Risk Management stated, He got up to go to the bathroom and he fell in his room. We transferred him to the hospital and the hospital called and told us it was a fracture. It was substantiated as neglect and an adverse incident. The patient was on 1:1 (one to one) and the CNA (Certified Nursing Assistant) left the room to answer another call and when she got back in the room the patient was on the floor. She was educated on neglect and abuse, exploitation and 1:1. The resident said she wasn't gone that long but that didn't matter. She should have called someone to come and assist her. He is still on 1:1 and in the Busy Bee Program 9:00 AM to 9:30 PM. On 11/17/22 at 1:00 PM, the Director of Nursing (DON) stated, On 8/30/22, the CNA found him on the floor. He stated he was going to the bathroom and lost his balance. He hit his head and complained of right hip pain. The ARNP (Advanced Registered Nurse Practitioner) ordered to transfer him to the hospital. He was on 1:1 at night and during the day he goes to the Busy Bee program. The CNA alleges she was with him, heard another resident's call light go off and she stepped away for 5 minutes and when she came back the resident was on the floor. We didn't find out about the fracture until the next day on 8/31/22, x-rays were done at the hospital. We educated the staff on fall precautions, interventions and following the residents care plans. We did education on abuse, and neglect and did a competency test. Audited all our 1:1 orders and had actual 1:1 sitter with our patients. We audited all fall care plans for our residents to ensure what is in the care plan is actually in the room and to ensure the interventions were appropriate for the residents . Busy Bee Program is a 12-hour program, 7 days a week sponsored by one of our foundations with a calendar full of activities. CNAs who have been trained and designated for that program. A calendar full of activities and have different departments that participate in the program. Three CNAs in the program for 15 residents, 5:1 ratio (5 residents per 1 CNA) and haven't had any falls since the program was started. Our fall rate has improved. The Busy Bee Program has been existence since October 2021 for 1 year. He started on the sensor on 8/04/22. On 11/17/22 at 2:27 PM, during a telephone interview with Staff A, Certified Nursing Assistant (CNA) in the presence of the DON, Staff A stated, I was working 11:00 to 7:00. I was assigned to 8 patients. I was taking blood pressure for another patient, and I heard a noise in [ Resident #1] room. I went to his room, and I saw him on the floor. I called the nurse. I was not on 1:1 with the resident. The nurse called the supervisor, and the supervisor came and then they took him to the hospital. I know if I am on 1:1 with a patient, I do not leave that patient for nothing. I don't remember receiving in-service on 1:1 supervision and following care plans from the DON and Risk Manager. Subsequent interview and record review with the DON on 11/17/22 at 3:32 PM concerning the CNA, (Staff A) assignment on 8/30/22 documented the CNA (Staff A) was assigned 8 residents on the shift. The DON revealed that the assignment for Staff A, CNA was 8 residents and not 1:1.

Based on observation, record review and interview, the facility failed to provide adequate supervision to ensure the safety of vulnerable residents and to prevent a fall that resulted in a major injury for one (Resident #1) out of three residents reviewed for falls. This practice has the potential to affect all 300 residents present in the facility at the time of the survey. The findings included: Record review of the facility's Fall Prevention Policy and Procedure (effective December 1990, revised April 2021) documented the following: Procedures-1) When a resident is admitted to the facility: a) The nurse will complete a Fall Risk Screening Tool as part of the resident's admission evaluation; b) The Fall Risk Screening tool will determine if the resident is at a High, Moderate or Low Risk for Falls; c) Interventions and medication management will be planned implemented and documented according to each resident's risk level and individual needs; e) The residents fall risk status will be communicated to all staff members caring for the resident through the resident's care plan. Review of the [alert system] for Fall Prevention Policy and Procedure (effective August 4, 2022, revised October 5, 2022) documented the following: Purpose-Implement [alert system] as a part of fall prevention strategy that meets the residents' needs by allowing them to maintain their routines without risking their safety; Procedures-The facility will implement [alert system] using artificial intelligence sensors in patient rooms to inform Staff of movement in order to prevent falls. The [alert system] will be used to monitor residents at high risk for falls, that require close supervision as identified in the care plan. Observation of Resident #1 on 11/12/22 at 9:20 AM, revealed Resident #1 was sitting in a wheelchair in the third-floor activity room in the Busy Bee Program and his left leg was bandaged. Attempted to interview the resident but he did not participate in the interview. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted to the facility on [DATE] with diagnoses to include non-pressure chronic ulcer of right lower leg, non-pressure chronic ulcer of left foot, [CONDITION(S)] of liver, repeated Falls, diabetes mellitus, chronic obstructive pulmonary disease, hypertensive chronic kidney disease, major depressive disorder, paranoid [CONDITION(S)], mild cognitive impairment, anxiety, [CONDITION(S)], and mood disorder. The resident was discharged on [DATE] with a fracture of head of right femur and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #1 dated 7/25/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment. The resident required extensive assistance with one-person physical assist for ADLs (Activities of Daily Living) and extensive assistance with two + (plus) persons physical assist for transfers. No alarms (bed, chair, motion sensor) were used. Review of the Physician' s Order Sheets (POS) and Medication Administration Records (MAR) for Resident #1 for August 2022 through November 2022 documented the resident was receiving insulin medication and antidepressant medications: Insulin [MEDICATION(S)] 100 unit/ml (ml) Solution Pen-injector inj (inject) 65 unit subq (subcutaneous) one time a day for diabetes mellitus, [MEDICATION(S)] (Hydro Chloride) DR (Delayed Release) 60 mg (milligrams) cap (capsule) 1 cap PO (by mouth) one time a day for depression and [MEDICATION(S)] XL (extra-long) ER (extended release) 24 hour 300 mg tab (tablet) 300 mg PO in the morning for depression. Also documented were the following orders: 1:1( one to one) Sitter/Monitoring around the clock every shift (Start 2/13/22; End 7/08/22); Transfer out to [Local Hospital] ER (emergency room ) for evaluation Dx (diagnosis): Head Trauma/Right Hip Pain (Revision 8/31/22); Resident needs continuous supervision, may attend the busy Bee Program during the day from 0930 AM to 9:30 PM (Revision 9/04/22); Fall precautions as care planned every shift for prevention of falls, ensure fall precautions are in place as specified in the care plan (Start 9/05/22); 1:1 Monitoring during hours of sleep, resident may be monitored with the [alert system] sensor when 1 to 1 is not available (Start 9/08/22), May use [alert system] Predictive Fall Prevention and Close Supervision (1:1 sitter, [alert system] Device or Busy Bee Program) (Start 10/11/22). Review of Resident #1's Treatment Administration Records (TAR) for August 2022 through November 2022 documented the following: Fall precautions every shift (Start 1/20/22); Out of bed with assistance, only contact guard and rolling walker every shift (Start 1/20/22); May use alarm Predictive Fall Prevention every shift for prevention of falls; Ensure fall precautions are place as specified in the care plan (Start 8/23/22) and Resident needs continuous supervision, may attend the Busy Bee Program during the day from 0930 AM to 9:30 PM every shift for safety (Start 8/23/22). The TAR on 8/29/22 documented the alarm sensor was in place and working for day and night. Review of Resident #1's Fall care plan dated 1/23/22 documented the resident was at risk for falls related to incontinence, history of falls, unaware of safety needs daily use of antidepressant medication, unable to follow instructions and impulsive to get out of bed on his own without calling for assistance; Goal: Resident's risk for serious injury will be reduced through the review date; Interventions: Close supervision (1:1 sitter, [fall alert system] Device or Busy Bee Program) every shift; Document methods of supervision used during the shift (date initiated 10/31/22); Bed in lowest position (date initiated 10/11/22; revision 10/11/22); Call light within easy reach (date initiated 1/23/22); Encourage/educate resident to use call-light for assistance (date initiated 9/23/22). Resident #1 also had the following care plans: ADLs, Impaired Cognitive Function, Diabetes Mellitus, Antidepressant, Major Depressive Disorder, [CONDITION(S)] Meds, Anxiety and [CONDITION(S)]. Review of the falls list dated August 2022 to November 2022, documented that Resident #1 had a fall on 8/30/22 with the resident found on the floor and sustained a bruise. Review of the Adverse Incidents Log dated August 2022 to November 2022, documented an incident with Resident #1 occurred on 8/30/22, the 15-day report was filed on 9/13/22 and the findings were substantiated. Review of the immediate federal report for Resident #1 documented the following: Date/Time of Incident: 8/30/2022 0031; Type of Incident: Neglect; Outcome: Fracture or dislocation of bones or joints; Description of Incident: On 08/30/22, resident was found on the floor by a CNA. He was assisted from floor to bed. he was assessed and no injuries noted but he complained of hip pain. Nurse Practitioner was notified, and order was given to transfer resident to the hospital for further evaluations. Upon investigation, it was found that the resident needed a 1 to 1 sitter due to high risk for fall. While the continuous monitoring was in the place, the CNA stepped away and upon her return back to the room, the resident was found on the floor stating, I was going to go the bathroom, lost my balance and fell . Review of the five-day federal report for Resident #1 documented the following: Investigative Findings: The hospital called the facility to report that resident sustained a right hip injury. Upon investigation, CNA monitoring the resident did not witness the fall. The incident is substantiated.; Allegation Substantiated: Yes; Correct Actions/Actions to be taken: The facility educated the staff on the One to One, Abuse, Neglect and Exploitation. Review of the progress notes for Resident #1 documented the following: Dated 8/30/22 00:00-Fall Note: Resident was found on floor by CNA. Observed resident on his right side by bathroom entrance. Resident stated he was trying to go to the bathroom and lost his balance. Resident hit top of head. No visible injuries noted. Resident c/o (complained of) right hip pain. Supervisor notified. ARNP (Advance Registered Nurse Practitioner) notified and next of kin notified; Dated 8/30/22 00:05-Fall Note: Staff nurse call to report fall, upon arrival resident in bed stated he was going to bathroom and lost his balance and fell , stated he hit his head, denies loss of consciousness, also c/o (complained of) right hip pain with movement between 3-5 scale on 1-10, resident stated he didn't use call light because he can do it on his own. ARNP on duty made aware of findings, order received to transfer to local hospital ER (emergency room ) for further evaluation and CT (computerized tomography) scan. Same was done resident was transfer with rescue, family made aware; Dated 8/30/22 05:23-Transfer to hospital and Dated 8/30/22 09:53-Call placed to the hospital report received the ER nurse she said that resident is admitted for right head femur fracture. Review of Resident #1's X-Ray reports revealed Hips Bilateral 2 Views Pelvis X-Rays dated 8/30/22 documented the findings/impression were: Complete right femoral neck fracture with mild displacement and angulation. Review of the Fall Risk Assessment Form for Resident #1 dated 6/01/22 documented the resident was High Risk for Falling with a score of 75.0. On 11/17/22 at 12:26 PM, the Director of Risk Management stated, He got up to go to the bathroom and he fell in his room. We transferred him to the hospital and the hospital called and told us it was a fracture. It was substantiated as neglect and an adverse incident. The patient was on 1:1 and the CNA (Certified Nursing Assistant) left the room to answer another call and when she got back in the room the patient was on the floor. She was educated on neglect and abuse, exploitation and 1:1. The resident said she wasn't gone that long but that didn't matter. She should have called someone to come and assist her. He is still on 1:1 and in the Busy Bee Program 9:00 AM to 9:30 PM. On 11/17/22 at 1:00 PM, the Director of Nursing (DON) stated, On 8/30/22, the CNA found him on the floor. He stated he was going to the bathroom and lost his balance. He hit his head and complained of right hip pain. The ARNP (Advanced Registered Nurse Practitioner) ordered to transfer him to the hospital. He was on 1:1 at night and during the day he goes to the Busy Bee program. The CNA alleges she was him, heard another resident's call light go off and she stepped away for 5 minutes and when she came back the resident was on the floor. We didn't find out about the fracture until the next day on 8/31/22, x-rays were done at the hospital. We educated the staff on fall precautions, interventions and following the residents care plans. We did education on abuse, and neglect and did a competency test. Audited all our 1:1 orders and had actual 1:1 sitter with our patients. We audited all fall care plans for our residents to ensure what is in the care plan is actually in the room and to ensure the interventions were appropriate for the residents. We are continuing got do the audits every 3 months. We started a PIP (Performance Improvement Plan) that monitors the effectiveness of the audits. We did find we have some improvement in our care plans-90% in compliance in fall interventions are appropriate for resident and 100% in our 1:1 orders and to make sure the interventions are in place. Busy Bee program is a 12-hour program, 7 days a week sponsored by one of our foundations with a calendar full of activities. CNAs who have been trained and designated for that program. A calendar full of activities and have different departments that participate in the program. Three CNAs in the program for 15 residents, 5:1 ratio (5 residents per 1 CNA) and haven't had any falls since the program was started. Our fall rate has improved. The Busy Bee Program has been existence since October 2021 for 1 year. He started on the sensor on 8/04/22. On 11/17/22 at 2:27 PM, during an interview via telephone with the Certified Nursing Assistant (CNA) Staff A in the presence of the DON, Staff A stated, I was working 11-7. I was assigned to 8 patients. I was taking blood pressure for another patient, and I heard a noise in [Resident #1] room. I went to his room, and I saw him on the floor. I called the nurse. I was not on 1:1 with the resident. The nurse called the supervisor, and the supervisor came and then they took him to the hospital. I know if I am on 1:1 with a patient, I do not leave that patient for nothing. I don't remember receiving in-service on 1:1 supervision and following care plans from the DON and Risk Manager. Subsequent interview and record review with the DON on 11/17/22 at 3:32 PM concerning Staff A's Assignment on 8/30/22 documented the CNA (Staff A) was assigned 8 residents on the shift. The DON revealed that the assignment for the CNA (Staff A) was 8 residents and not 1:1.

Based on records reviewed and interviews, the facility failed to demonstrate an effective plan of action was implemented to correct identified deficient practice in problem-prone areas, related to reporting of abuse, neglect and exploitation within the required timeframe, as evidenced by repeated deficient practice identified related to the reporting of abuse and neglect (Cross Reference F 609). The findings included: Record review of the facility's survey history revealed, during a complaint survey with exit dated August 12, 2021 the facility failed to report an incident related abuse an injury of unknown origin within two hours for two residents (Resident #1 and Resident # 4). During this complaint survey with an exit date of April 04, 2022, repeated deficient practice was cited related to the facility's failure to submit a report for a neglect incident that occurred on March 25, 2022 related to a fall resulting in injury (fracture) sustained by Resident #3. Review of the AHCA Immediate Report revealed the initial submission for Resident #3's incident was done on March 28,2022 at 5:21 PM which was three days after the incident occurred. The documented Date and time of the incident was on March 25,2022 at 3:51 PM. Type of incident: Neglect. Interview with the Director of Quality on 4/5/22 at 1:45 PM revealed the facility was aware that the incident regarding Resident #3 occurred on 3/25/22 and the Federal Immediate related to alleged Neglect was not submitted until Monday 3/28/22. The staff has all been trained that all incidents involving injuries and or transfers need to be reported right away to the Risk Manager. This can be done by the Nurse completing the incident report or the Supervisor. This was an error in reporting as the Risk Manager was not notified of the fall with fracture and hospitalization until 3 days after the incident; therefore, the Immediate Report was submitted late. Review of the facility policy and procedure titled Abuse, Neglect Exploitation, Mistreatment, and Misappropriation of Resident's Property Prevention revised 04/2021 revealed: Reporting/Response: a. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required (i.e. DCF (Department of Children and Families), AHCA, Board of Nursing) and take all necessary corrective actions depending on the results of the investigation. b. In response to allegations of abuse, neglect, exploitation, or mistreatment: the facility will: Ensure that all alleged violations involving abuse, neglect exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, or if the event involves abuse R serious bodily injury, are reported immediately, but no later than 2 hours after the allegation is made. If the allegation does not involve abuse or serious bodily injury, the allegation will be reported no later than 24 hours, to the administrator of the facility and to other officials (i.e. DCF, AHCA).

Based on record review and interview, the facility failed to report an allegation of neglect related to a fall within the required timeframe of the incident for one (Resident #3) of three residents reviewed for neglect as evidenced by Resident #3 sustained a fall with fracture on 3/25/22 and the Federal Immediate report was not submitted to the AHCA (Agency for Healthcare Administration) until 3/28/22. The Abuse Registry was not notified until 3/28/22. The finding included: Review of the facility policy and procedure titled Abuse, Neglect Exploitation, Mistreatment, and Misappropriation of Resident's Property Prevention revised 04/2021 revealed: Reporting/Response: a. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required (i.e. DCF (Department of Children and Families), AHCA, Board of Nursing) and take all necessary corrective actions depending on the results of the investigation. b. In response to allegations of abuse, neglect, exploitation, or mistreatment: the facility will: Ensure that all alleged violations involving abuse, neglect exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, or if the event involves abuse R serious bodily injury, are reported immediately, but no later than 2 hours after the allegation is made. If the allegation does not involve abuse or serious bodily injury, the allegation will be reported no later than 24 hours, to the administrator of the facility and to other officials (i.e. DCF, AHCA). Record review of the demographic face sheet for Resident #3 revealed the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was transferred to the hospital on 3/25/22 and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the comprehensive 5-day minimum data set (MDS) dated [DATE] revealed, Resident #3's BIMS (brief interview for mental status) score was 12 out of 15 indicating moderately impaired cognitive status. Resident #3 required extensive assistance for ADL's (activities of daily living) and mobility devices included a walker and wheelchair. Resident #3 sustained one fall with major injury since admission and was receiving special services to include skilled physical therapy (PT) and occupational therapy (OT). Review of Resident #3's care plan revealed: Risk for falls related to gait/balance problems, limited mobility, requires ADL assist, use of [CONDITION(S)] meds, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include medications as ordered, monitor side effects, bed in low position, call light in reach, incident of fall 3/25/22. Neurochecks every shift. PT/OT. Fall risk precautions. Review of the nursing progress notes for Resident #3 documented on 3/24/22 indicated: Patient appears agitated and wanted to go home today. Social Worker spoke to family who wanted patient to stay for therapy. Call placed to doctor with new order for psychiatry and [MEDICATION(S)] 1 mg (milligram) q (every) 6 hours as needed. Safety measures in place. Patient refused to have labs drawn. [MEDICATION(S)] 1 mg administered - effective. Noted dated 3/25/22 timestamped 05:22 [MEDICATION(S)] 1 mg administered, effective. Note dated 3/25/22 time stamped 15:51 indicated: Upon round by staff, nurse was called to room. On assessment, resident noted laying on his right side on the floor next to the bed. Eyes open verbally responsive, complaining of pain to right hip. Resident transferred back to bed via lift with 2 persons. PRN (as needed) Tylenol given. Call placed to doctor who ordered X-ray, post fall with Neuro checks. Supervisor made aware. Wife [name] notified. X-ray done, result pending. Safety measure - bed in low position. Call light in reach. Note dated 3/25/22 timestamped 19:47: X-ray right hip. Impression - acute comminuted fracture right femur. 20:07 Results reported to MD (medical doctor) and APRN (Advanced Practice Registered Nurse). Order to send via 911. Patient's wife and brother made aware of transfer. Nursing supervisor made aware. Note dated 3/31/22 timestamped 12:16 documented: On 3/25/22 Resident was found on the floor to the R side of the bed. Resident is [AGE] year old admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Right after admission he started to exhibit periods of agitation and confusion. MD (Medical Doctor) notified and gave new orders for labs and psych consult. Treatment was refused by patient. He attempted to get out of bed and fell . He has muscle weakness, impaired balance, and restlessness episodes. Per PCP (primary care physician), patient needs close monitoring. Documentation dated 4/2/22 readmitted . 4/2/22 fall risk assessment completed. Resident has score of 50 on this most recent assessment. Care plan updated. Review of the physician's orders for Resident #3 revealed an order dated 4/4/22 for 1:1 (one to one) sitter/monitoring around the clock. Review of Resident #3's Fall Risk assessment dated [DATE] revealed a risk score 26 (moderate). No history of falls. Review of the Fall Risk assessment dated [DATE] revealed a risk score 50 (high risk). Review of the AHCA Immediate Report revealed the initial submission for Resident #3's incident was done on 3/28/22 at 5:21 PM which was three days after the incident occurred. Date and time of incident 3/25/22 at 3:51 PM. Type of incident: Neglect. Resident admitted to the facility on [DATE] with metabolic [CONDITION(S)], [CONDITION(S)] with acute exacerbation, [CONDITION(S)], hypertensive heart and chronic kidney disease with heart failure, among others. The patient is also very agitated wanting to go home. On March 25, 0222 at approximately 15:51, upon round by staff, nurse was called to the room. On assessment, resident noted to be laying on his right side to the floor by the foot of the bed. Resident's eyes were open and he was verbally responsive, complaining of pain to the right hip. Resident transferred back to bed. Call placed to provider, gave orders for X-ray to right hip. Patient positive results of X-ray state Acute comminuted fracture of intertrochanteric right femur. Patient was transferred to the hospital for evaluation. Interview with the Director of Nursing (DON) on 4/5/22 at 10:10 AM revealed Resident #3 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported; He was here for short term rehab. He did have some agitation related to placement. He wanted to go home. The physician ordered [MEDICATION(S)] for his Anxiety. He calmed down with the use of the medication. His first fall risk assessment was done 3/23/22 on the day of admission and we did not find him at high risk for at the time. He had no history of falls. He was agitated but he was not trying to get out of bed. We did not anticipate that he would sustain a fall and felt this incident was not under the facility's control. On the day of the fall the Speech Therapist (ST) came to evaluate him. After she left the room, the housekeeper walked by and found him on the floor. The nurse was notified and upon assessment he complained of right hip pain. Tylenol was administered. The MD was notified and an x-ray was ordered . Neuro checks initiated. The x-ray was done in the facility and results were positive for right hip fracture. He was sent out to the hospital on 3/25/22. We did not report the incident to the Risk Manager on time so the federal immediate report was not submitted until 3/28/22. This should have been reported to the Risk Manager on 3/25/22. The staff reported this was a hectic day and they failed to call the Risk Manager. They completed the incident report but they did not call Risk Manager so she could submit the Immediate Report to AHCA. Interview with Registered Nurse Manager (Staff A) on 4/5/22 at 1:46 PM revealed she was not present at the time of Resident #3's fall. I was involved in the investigation on Monday 3/28/22. He fell on the day shift, but the x-ray results did not come in until 7:47 PM which is after the shift change. He was transferred to the hospital with a right comminuted fracture of the femur. The nurse (Staff B) was the person responsible to report the incident to the risk manager and complete the incident report. She did complete the incident report, but the x-ray results were not available on her shift. This may be the reason she did not notify the Risk Manager of the incident. Interview with Registered Nurse (Staff B) on 4/5/22 at 2:27 PM revealed on the 7:00 AM to 7:00 PM shift the day of the incident, ST came into the resident rooms to do a swallow evaluation. I was passing meds and the housekeeper alerted me that he was found on the floor next to the bed. He was complaining of pain. We used a lift to put him back to bed. I reported to the Nurse Manager (staff A). We called the doctor and the family. X-rays were ordered and done in the facility. The results were not in by the end of my shift. It was the next shift who sent him out to the hospital. I completed an incident report which is what I am supposed to do. When there is an incident report entered into the system it is picked up by Risk Management. It is my responsibility to contact the doctor, family, and Nurse Manager. I also do the incident report in the system. It is not my responsibility to notify the Risk Manager. Interview with the Director of Quality on 4/5/22 at 1:45 PM revealed the facility was aware that the incident regarding Resident #3 occurred on 3/25/22 and the Federal Immediate related to alleged Neglect was not submitted until Monday 3/28/22. The staff have all been trained that all incidents involving injuries and or transfers need to be reported right away to the Risk Manager. This can be done by the Nurse completing the incident report or the Supervisor. This was an error in reporting as the Risk Manager was not notified of the fall with fracture and hospitalization until 3 days after the incident; therefore, the Immediate Report was submitted late.

Based on record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one resident (Residents # 4) out of four sampled residents as evidenced by Resident # 4 was found on the floor on 7/10/2021 at 5:51 PM, the x-rays results came in the same day at 10:14 PM indicating Resident # 4 had a femur [CONDITION(S)]. The facility sent the resident for higher level of care 10 hours after they received the x-rays results. There were three-hundred twelve residents residing in the facility at the time of the survey. The findings included: Review of the face sheet for Resident #4 revealed an admitted on 5/28/2021. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed a Brief Interview Mental Status (BIMS) of 3 out of 15, indicating cognitive impairment. In the functional status, resident required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene and activity occurred once or twice for walking and locomotion. Review of the nursing progress notes for Resident #4 revealed that on 7/10/2021 at 5:51 PM Resident #4 was found on the floor by the Certified Nursing Assistant (CNA). Resident # 4 fell while attempting to get out of bed. He stated that he was going to open the door. The resident was assessed and reported no pain. However, the patients old skin tears were reopened. Record review revealed on 7/10/2021 at 6:23 PM, the Advanced Registered Nurse Practitioner (ARNP) ordered a Bilateral hip x-ray, physical therapy evaluation, occupational therapy evaluation, and wound care consult status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the radiology/diagnostic results dated 7/10/2021 at 10:14 PM revealed that x-ray bilateral hips were done. Findings showed on the left, there was a fracture of the neck of the left femur with cephalic migration of the distal fragment. A telephone call was placed to Resident's #4 primary doctor and a message was left to call the reading radiologist at the time of the interpretation. On 7/11/2021 at 10:24 AM, the nursing progress notes revealed x-ray result were reported to the ARNP at 10:20 AM. An order was received for orthopedic consult and Resident #4 left facility via 911 at 11:10 AM. On 7/11/2021 at 7:22 PM the facility made a call to a local hospital to check on the status of Resident #4. They confirmed that the resident had a femur [CONDITION(S)] and was in the emergency department awaiting a room. On 08/12/2021 on 10:34 AM, during an interview with Registered Nurse (RN) Staff A, (via telephone) it was stated that the Certified Nursing Assistant (CNA) was doing rounds, and found the Resident # 4 sitting on the floor to the right side of the bed. A full assessment was done of the resident and no bruises were found. Resident verbalized no pain at that time, but Tylenol was ordered for pain as needed. Staff A, RN reported that Resident # 4 stated that he was about to open the door, because someone was knocking, but nobody was knocking at that time. Resident #4 is alert and oriented to person but not time or place, and he is confused most of the time. 08/12/2021 at 11:26 AM, during an interview with Staff B, RN Supervisor (via telephone) revealed that she knew Resident # 4, but she did not know why the resident was sent to the hospital next day. Staff B explained that she did not order the resident to be transferred because the doctor was the one who ordered the resident to be transferred to the hospital. On 08/12/2021 at 12:30 PM during an interview with the Director of Nursing (DON) and Risk Management (RM); it was revealed that according to the records, Resident #4 had a fall on 7/10/21 at 5:40 PM. They did x-rays of both hips and the results indicated that Resident #4 had a fracture of the left femur. At 10:14 PM, they called the physician to report the findings. The physician called back the next day at 10:00 AM in the morning. The DON was asked why the facility took so long to send Resident # 4 to the hospital and what would be done in case they could not find the doctor why they did not contact another doctor to get an order to send the resident to the hospital. The DON stated that they would try to contact the physician and if they could not contact the physician, they would move to the next physician. The DON explained that Resident # 4 is a private physician. They would have to contact the family to find another physician. The DON reported that she did not see any documentation in Resident # 4's records to indicate that the family was contacted and informed that the physician could not be reached and get permission to contact another doctor. The RM stated that Resident # 4 was not oriented and had not received any pain medication.

Based on record reviews and interviews, the facility failed to report an incident related abuse, neglect for injury of unknown origin within two hours for two residents (Resident #1 and Resident # 4) out of four sampled residents. As evidenced by Resident #1 was found by the night nurse at 4:00 AM with a hematoma of unknown origin to the right frontal area on 6/27/2021 at 4:00 AM and reported injury to the oncoming nurse at 6:10 AM but the immediate report initial submission was not done until 11:53 AM. and 2) Resident #4 was found on the floor on 7/10/2021 at 5:51 PM, the x-rays results came in the same day at 10:14 PM indicating the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . There were three-hundred twelve residents residing in the facility at the time of the survey. The findings included: Review of the Abuse, neglect, exploitation, misappropriation of residents' property mistreatment, and injuries of unknown origin Policy and Procedure, last reviewed 04/2021, revealed In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, or if the event involves abuse or serious bodily injury, are reported immediately, but not later than 2 hours after the allegation is made. If the allegation does not involve abuse or serious bodily injury, the allegation will be reported no later than 24 hours, to the administrator of the facility and to other officials (i.e., DCF, AHCA). 1) Review of the face sheet for Resident #1 revealed admitted [DATE]. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing notes for Resident #1 dated 06/27/2021 revealed; during rounds resident was noted with a large hematoma to the right side of her head. The resident was asked what happened. The resident stated that she did not know and denied pain and discomfort. The documentation indicated that report was received from night nurse that Resident#1 was found sitting in a chair in room attempting to get up at 4:00 AM with a large hematoma to the right side of her head. The supervisor was informed. The Supervisor contacted the Nurse Practitioner for orders to transfer the resident to a local hospital. Record review revealed no documentation completed by the night nurse that discovered the resident at 4:00 AM with the hematoma to the right side of the head. Review of progress notes dated 06/27/2021 for Resident #1 revealed When passing meds at 06:10 AM, I found the resident sitting on a chair with a big hematoma to the right frontal area of the skull. Resident awake, alert, disoriented, no signs of distress noted. Resident could not explain how that happened. Supervisor made aware at 06:15 AM, supervisor texted ARNP at 06:40 AM and 06:55 AM. At 07:10 AM supervisor decided to send resident to local hospital. Review of the Immediate Report revealed an initial submission for Resident #1's, incident was submitted by the facility on 6/27/2021 at 11:53.17 AM, which was over 6 hours after the incident occurred. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Started Date 03/21/2021. The medication was held on 06/27/2021 to 06/30/2021. Review of the Annual Minimum Data Set (MDS) for Resident # 1, dated 07/11/2021 revealed a Brief Interview for Mental Status summary score of 3 out of 15, indicating cognitive impairment. For Functional Status, Resident # 1 required total dependence for transfer, locomotion, personal hygiene, and toilet use with two persons to physical assist. The resident needed extensive assistance for bed mobility, dressing, eating with one physical person. On 08/11/2021 at 1:33 PM during an interview with the Risk Manager (RM) and Vice-president for Clinical Services (VPCS) it was revealed that Resident # 1 was found with a large hematoma on the right side of the face. The resident was found on 06/27/2021 at 6:10 AM and it was reported to the Risk Manager at 7:10 AM. A total assessment of the resident was done to check if there were any other issues. The Risk Manager staled that the resident touched the hematoma and did not show any signs of pain. The Nurse Practitioner ordered for the resident be sent to the hospital for a CT(computerized tomography) scan of the brain. The conclusion of the CT scan indicated; Large Right Frontotemporal Scalp Hematoma, no evidence of acute large vascular infarct or acute intercranial hemorrhage, no underlying calvaria (the top part of the skull) fracture. Stable chronic appearing microvascular ischemic changes. The resident came back to the facility and was placed on close supervision with more rounds being done to monitor the resident. The resident is not ambulatory, but she can move over on the sides of the bed. She is taking [MEDICATION(S)] 2.5 milligrams one tablet by mouth twice a day. The Immediate report was done at 10:25 AM and the investigation was reported within the five days after the incident. The RM stated that she started to call the Department of Children and Families (DCF) but when she called the hot line she was on hold for more than one hour before they took the call. 2) Review of the face sheet for Resident #4 revealed an admitted [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] for Resident # 4 revealed a Brief Interview Mental Status (BIMS) of 3 out of 15, indicating cognitive impairment. In the functional status, resident required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene and activity occurred once or twice for walking and locomotion. Review of the nursing progress notes for Resident #4 revealed that on 7/10/2021 at 5:51 PM Resident #4 was found on the floor by CNA (Certified Nursing Assistant). Patient fell while attempting to get out of bed. He stated that he was going to open the door. Patient was assessed upon fall. Patient reported no pain. However, patients old skin tears were reopened upon fall. Skin tears on right forearm. On 7/10/2021 at 6:23 PM, the Advanced Registered Nurse Practitioner (ARNP) ordered a Bilateral hip x-ray, physical therapy evaluation, occupational therapy evaluation, and wound care consult status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Radiology/Diagnostic Results dated 7/10/2021 at 10:14 PM revealed that x-ray of the bilateral hips were done. Findings showed on the left, there was a fracture of the neck of the left femur with cephalic migration of the distal fragment. A telephone call was placed to Resident's #4 primary doctor and a message was left to call the reading radiologist at the time of the interpretation. On 7/11/2021 at 10:24 AM, the nursing progress notes revealed; x-ray result was reported to the ARNP at 10:20 AM. An order was received for orthopedic consult. Resident #4 left facility via 911 at 11:10 AM. On 7/11/2021 at 7:22 PM the facility made a call to the local hospital to check on the status of Resident #4. The local hospital confirmed the resident had a femur [CONDITION(S)] and the resident was in the emergency department awaiting a room. Review of the Immediate Report submission time for Resident #4 revealed that the facility reported the incident on 7/11/2021 at 10:41 AM. This was 15 hours after the incident occurred. On 08/12/2021 at 12:30 PM during an interview with the Director of Nursing (DON) and the Risk Management (RM); it was revealed that according to the record, Resident #4 had a fall on 7/10/21 at 5:40 PM. They did x-rays to both hips and the x-ray result indicated that Resident # 4 had a fracture in the left femur. At 10:14 PM, the facility called the physician to report the findings. The physician called back the next day at 10:00 AM. The RM stated that the immediate report was done on 7/11/2021 at 9:30 AM because that was the time she was notified and she did not check the progress notes because she was not in the facility. The process started when they received the x-ray results and the call the dedicated number. The DON stated that the facility have 2 hours to report from the time that allegation is made.

Based on record reviews, observations and interviews, the facility failed to ensure emergency equipment specifically portable suctioning machines and the wall suctioning system were adequately maintained and functioning in an event of an emergency to maintain a patent airway during Cardio Pulmonary Resuscitation (CPR) for one out of 2 (Resident # 492) sampled whose diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was determined that this deficient practice posed immediate Jeopardy (IJ) which is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility failed to ensure the ordered oxygen level for 2 out of 2 residents sampled (Resident #561and #99) out of the 39 residents residing in the facility that required respiratory treatment. The Immediate Jeopardy (IJ) was determined to be past noncompliance. The IJ started on [DATE] and the facility removed the immediacy on [DATE], the IJ was corrected on [DATE] when the re-education of staff had been completed. The findings included: Record review of the federal reported incident revealed, on [DATE] during breakfast time Certified Nursing Assistant (CNA) observed Resident # 492 nonresponsive and called the nurse to Resident # 492's room. The resident was not responsive to arousal and Cardio Pulmonary Resuscitation (CPR) was initiated. During CPR, a copious amount of brown emesis was noted in the resident's mouth, attempts were made to suction the resident but the suction machine that was delayed in arriving was not working when it was turned on and the wall suctioning system was not working. Emergency Medical Services arrived and the Automated External Defibrillator (AED) was used but the resident was nonresponsive and expired in the facility at 10:08 AM. Review of the clinical records revealed, Resident # 492 was admitted to the facility on [DATE] from a local hospital. Resident #492's Advance Directive revealed, the resident was a Full Code and cognitively intact. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Allergies documented were [MEDICATION(S)]. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Stop [MEDICATION(S)], start [MEDICATION(S)] 40 mg IV once daily x 7 days for GI (Gastro intestinal) prophylaxis. Start [MEDICATION(S)] 80 mg chewable tablet three times daily. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start IV fluids 0.45 % normal saline at 75 milliliter per hour (ml/hr). May place midline if needed. Order dated [DATE] at 2:48 PM- [MEDICATION(S)] 10 mg/2 ml vial IM x 1 dose stat for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the progress notes by the Advanced Registered Nurse Practitioner (APRN) dictation dated [DATE] indicated but were not limited to: {Resident's name} is being seen for medical follow-up today for report of episode of nausea and vomiting last evening. He was seen and evaluated by on duty-APRN on last evening. Lab work and diagnostic studies including stat KUB (kidney, ureter, bladder) and chest x-ray were completed for him. Presently he is awake and alert, oriented x (times) 3. He appears diaphoretic (sweating heavily). He reports that he has had 4 episodes of vomiting today. He has not been able to keep down his breakfast or his lunch. Vital signs have remained stable throughout the day. He was noted to have emesis stains on his gown and bed sheet, which are dark in color. He denies chest pain, palpitations, shortness of breath or dyspnea. He reports that he has abdominal pain around the umbilical area. He reports that he has been voiding today. Assessment and Plan: 1. Dehydration/nausea and vomiting. we will initiate IV (intravenously) fluids of 0.45% normal saline at 75 ml (milliliters) per hour. [MEDICATION(S)] 4 mg (milligram) IM (intramuscular) x (times) 1 to be given now. Review of the Medication Administration Records (MAR) for [DATE] revealed, the following ordered medications were signed off as given on the day of the incident: [MEDICATION(S)] tablet 88 MCG (micrograms) 1 tablet for [CONDITION(S)] ordered for 6:00 AM. [MEDICATION(S)] sodium solution reconstituted 40 mg intravenously ordered for 6:00 AM, [MEDICATION(S)] tablet 500 mg, give 1 tablet by mouth every 8 hours for Diverticulitis for 7 days start date [DATE] noted 6:00 AM dose given, [MEDICATION(S)] tablet 25 mg give 1 tablet by mouth every 6 hours signed off as given for 6:00 AM dose, [MEDICATION(S)] tablet 25 mg 1 tablet by mouth one time a day for [CONDITION(S)] (hypertension) ordered for 9:00 AM, [MEDICATION(S)] capsule 150 mg, give 1 capsule by mouth two times a day for blood clot ordered for 9:00 AM and [MEDICATION(S)] tablet 25 mg, give one tablet by mouth two times a day for depression ordered to be given at 9:00 AM. Review ofthe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ordered diet with a start date of [DATE] documented: No Added Salt (NAS), pureed textured and nectar thicken liquids. Review of Resident # 492's breakfast meal ticket for [DATE] revealed standing orders for Mighty shake (no added sugar) honey thick and 6 ounces (Oz) super cereal puree. Dining location indicated, resident eats in room and no allergies noted. Resident # 492's required setup help only for eating. Review of Resident # 492's baseline care plan with effective date of [DATE] revealed, the resident required one person to physically assist with personal hygiene and for toileting two persons to physically assist. The resident was documented as being incontinent of bowel and bladder. The resident therapy services ordered included physical therapy, occupational therapy, and speech therapy. The baseline care plan indicated discharge plans initial goal for Resident to return to the community and discharge location anticipated was to an assisted living facility with assisted living staff as caregivers. Review of a witness statement signed by former employee Staff DD, a Certified Nursing Assistant (CNA) noted, around 9:30 AM, when I entered resident (room #) the resident had his breakfast tray in front of him, vomit was on his bed and he was unresponsive. When I called him many times I immediately called the nurse. Attempts made to interview Staff DD, CNA by telephone on [DATE] and [DATE] were unsuccessful. Review of the nurse's notes created [DATE] at 08:37:04 by Staff EE, Licensed Practical Nurse (LPN) indicated: Resident continues on IVF (intravenous fluids), well tolerated, midline in place to left arm, patent, resident shows no signs of respiratory distress, no c/o (complain of) pain voiced. Resident started on [MEDICATION(S)] 500 MG (milligram) by mouth every 8 hours for Diverticulitis for 7 days, no adverse reaction noted, afebrile, PO fluid encouraged. Attempt x 1 to straight catheter to collect urine, no urine obtained, resident said that he just urinated, safety and comfort maintained, call light in reach, will continue to monitor. Report given to AM nurse to follow up . Discharge summary notes created by Staff FF, a Licensed Practical Nurse (LPN) on [DATE] at 14:28:06 :Rounds made this morning, Patient received in bed alert and oriented tiems 3, eyes open while TV is turned on. Writer said good morning sir, my name is {}, I will be your nurse this morning. Patient replies good morning, when is breakfast coming. writer observed patient with a peripheral IV running, site intact and patent. During breakfast time nursing aide called nurse to the room, patient observed non-responsive. When trying to arouse patient, patient refuses to wake up or answer. CPR initiate. CODE BLUE, and Program of All-Inclusive Care for the Elderly (PACE) Medical Doctor (MD) and nurses here to assist in CPR. 911 contacted, Fire rescue arrives to facility, 4 rounds of [MEDICATION(S)] given to arouse patient, not well tolerated. Constant suctioning of the patient in progress. All nursing interventions done on patient and patient continues to be non-responsive. Review of the physician's documentation dated [DATE] at 17:02:52 indicated {nurse manager name} myself at bedside providing CPR. Noted to have vomited brown emesis and had remnants in oropharyngeal airway. Patient suctioned as had a pulse, airways secured and ventilated via ambubag, and CPR administered, EMS arrived and patient was Shocked on PEA (Pulseless Electrical Activity) with AED (Automated External Defibrillator) and 4 rounds of epi, one sodium [MEDICATION(S)] before I called code at 10:08 am. On [DATE] attempts were made to contact the physician on the contact number received from the facility and attempts by telephone were unsuccessful. Observations of the facility's medication rooms conducted between [DATE] and [DATE], revealed suction machines in the medication rooms of each unit in working condition. On [DATE] at 8:52 AM, the Director of Engineering and the Manager of Emergency Planning were asked who is responsible for the maintenance of the suction equipment. The Maintenance Manager stated that the high risk equipment is checked by a contracted service company that comes into the facility semiannually in May and November. The Director of Engineering explained, that high risk equipment is defined as the AED machines and based on the facility's internal judgement they added the suction machines were to the checked biannually. The wall systems however is checked by another contracted company. The Director of Engineering explained that when these companies come into the facility they are required to check 100% of the emergency equipment, an initial escort is done, it is possible but unlikely, we escort them we do not have to baby sit them, because the same individual comes for as long as I remember, they are the ones that put the green or blue stickers and it is dated but the electrical checks are done internally. On [DATE] at 9:10 AM, during an interview with the Director of Nursing and the Vice President of Clinical Services. The DON stated, the incident happened during breakfast and the staff had set up the resident's tray and when they returned they noticed he was unresponsive. The resident received his tray between 9:30 AM and 9:45 AM and CNA found him between 9:30 am and 9:45 am. The DON revealed, the resident was diabetic but did not have any orders for blood sugar checks and was able to feed himself and that the resident was a full code. The nurse that worked, was an agency nurse. I was the reporter of the incident; I received the allegation on [DATE] in the morning the allegation came from the physician that was present during the incident. The doctor reported that she was concerned that during the code blue she did not have a suction machine and she could have saved the patient if she had the suction machine. We did an extensive investigation; we interviewed all the staff involved. The nurse manager, the nurse and the CNA that observed the resident was not involved in the code blue and the Advanced Registered Nurse Practitioner (ARNP), the nurse manager and the physician no longer work with our facility also the CNA is no longer employed with us. We interviewed everyone present during the incident and we found that we did not have the suction machine readily available and it was not clear that even if we had a suction machine readily available and working if we would have saved the patient because we used other measures such as, turning the resident to the side, suction with the syringe and we were able to suction the emesis that was in the mouth with the syringe. The DON and Vice President of Clinical Services was asked if the resident should he have been suctioned, the DON stated it was not the practice for CPR, but because the physician was present at the time the resident would be suctioned. The expectation would be to perform basic CPR which did not include suctioning a patient. The criteria for suctioning would be if the patient were in the dining room choking or during a mealtime if the resident is having a snack and when the resident is noted to be breathing and observed to be choking, a licensed nurse can perform suctioning. Suctioning is performed with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON revealed, that the facility currently does not have any residents that require suctioning. The Ambu bag was used to clear the airway which is our best practice and what we teach during CPR because we are not a hospital. During the time of the code, we called 911 that was the first thing we did. The paramedics did shock the resident with the AED and 4 rounds of epi sodium [MEDICATION(S)] because the physician insisted. The time of death was 10:08 pronounced by the fire rescue. The DON stated, she does not have the time the CPR was started by the facility staff, but she has a copy of statements and interviews. The DON reported, a root cause analysis was done when the case was closed on [DATE], the DON stated, we found that we have areas of improvement such as the availability of equipment and supplies during the code. But we practice basic life support which is the expectation that we have for our nursing staff suctioning a patient during CPR was not part of our best practice, the policy was revised for CPR after the incident in [DATE]. The DON reported, the suction machine that was used came from 2 [NAME] and found out later on that it was working but no one knows why it was not working at that time of the incident. The DON stated, Either way we ordered fifteen new suctioning machines they were ordered on [DATE]. The DON revealed that the corrective actions that the facility implemented after the incident include: All suction machines were checked on [DATE], and the 15 additional suction machines were ordered and were provided to each unit, checklist will be updated to allow nurses to check crash carts and suction machines. Suction machines are checked for proper functioning daily by the unit nurse and weekly by the nurse manager. Audits were submitted to Quality department on a weekly basis and discrepancies evaluated for 2 months and after that the nurse managers are responsible to check weekly. Ongoing education provided to the nursing staff on how to properly work the suction machines and a competency check was completed. Additionally, all Crash Carts and keys were checked on [DATE]. The Crash carts will continue to be checked daily by the nurse, weekly by nurse managers and audits will also be submitted to the quality department for evaluation on an ongoing basis. The Code blue policy was updated to assure that the roles and responsibilities are clearly defined, education was provided to all Nursing staff on the new process and a quality tools developed to evaluate all code blue events. The DON reported, that the nurses were educated on the suctioning machine and best practice during code blue or patient assessment team call which is the facility's internal process. The DON stated, I did the training myself mock Code Blue in different sessions. The DON explained the trainings were done in the facility's auditorium and set up was as if they were in a patient's room and with return demonstration by all nursing staff. All the nurses and CNAs are required to have CPR training. If a CNA is in a room and notices a resident nonresponsive the CNA can start BLS (Basic Life Support) and call the nurse. Anyone can call a PAT (Patient Assessment Team) or code blue an internal response system is on the badges (copy requested) they call 222 and begin BLS which includes calling for help checking if resident is a DNR (Do Not Resuscitate) or full code if full code initiate CPR. During a code there is a team leader, the ARNP would be the lead and delegate the task to the team. If the ARNP is not present, the supervisor or nurse manager will assume the lead. When a CNA identifies an issue, they are required to get the nurse and the nurse goes into the room. On [DATE] at approximately 11:40 AM the Administrator (NHA), revealed the licensed nurses, the CNAs and all staff are held at a higher standard. The integrity of the staff and expectations are that we have a job to do and there are going to be incidents and nobody should sweep it under the rug whether good or bad. Risk is the most serious thing in this organization and the continuing education on what is reportable and as the NHA he wants to be notified of all incidents. I rather hear about it immediately. The NHA stated that the facility is required to take care of the resident because the family entrust the care on the facility. The NHA explained that he was not made aware of the incident until the next day, on [DATE] was when the doctor informed the DON of the incident and raised the questions during the morning meeting about the code and when the concerns were explained by the doctor the DON called in the report. The NHA revealed, that he was concerned that he was not informed until the following day and the CEO (Chief Executive Officer) was also involved because no one mentioned it or reported anything until the doctor mentioned the concerns in the morning meeting the day after the incident instead of at the point in time when the incident occurred, because it could have been reported earlier and it is part of the facility's Quality Assurance and Improvement (QAPI).The NHA stated, that he did not consider the incident an adverse incident. Review of the local fire department's ambulance run report narrative revealed, on [DATE] at 9:49 AM , male found at scene unresponsive. Patient (Pt) was found to be asystole. CPR was initiated continued for 30 minutes. Pt remained in asystole for the duration of the [CONDITION(S)]. Pt was pronounced dead in the field and Dr (doctor name and license) agreed with the crew's decision. Local police department was notified. On [DATE], the corrective actions implemented by the facility was verified by the survey team through observations, record reviews and staff interviews review of in services and trainings were conducted for all nursing staff.The facility's corrective actions included: Suction Machine 1. Check all suction machines by nurse managers [DATE]. 2. New suction machine for 2 M was ordered and arrived functioning properly on [DATE]. 3. Fourteen (14) additional machines were ordered from foster medical. 4. New checklist to allow nurses to check crash cart and suction machine developed. 5. Nurses will in-serviced and have a competency check on using suction machine. 6. Suction machines will be checked for proper functioning daily by the unit nurse, weekly by the nurse manager, biweekly. 7. Audits will be submitted to Quality on a weekly basis by Friday 5 pm, any discrepancies will be evaluated. Crash Cart 1. Crash carts were checked on [DATE] 2. Keys to all crash carts will be distributed to all nurses' key rings, ARNPs, key MJH physicians nurse managers and supervisors. 3. Crash cars will continue to be checked daily, weekly by nurse managers. Audit will be submitted to QAPI on a weekly basis on Friday 5 pm X 3 months. 4. Crash carts will be checked for supplies daily. Code Blue 1. Code blue policy will be updated to assure that the roles and responsibilities are clearly defined. 2. Education will be provided to all nurses, Nurse managers and all related staff on the new process. 3. ARNPs will perform mock codes with the support of education. 4. A quality tool completed by the leader of the code will be completed and scanned over to quality. 2 ) Observation on [DATE] at 10:39 AM revealed, Resident #561 in bed with nasal cannula in place at 4 Liters (L) per minute. Resident # 561 did not appear to be in any pain or distress. (photographic documentation obtained of O2 settings) Observation on [DATE] at 12:28 PM revealed, Resident #561 in bed with nasal cannula in place at 4 Liters per minute. Resident # 561 did not appear to be in any pain or distress. On [DATE] at 8:22 AM, Resident #561 was observed in bed eating breakfast, the nasal cannula was in place and oxygen level was at 4 Liters per minute. Review of the clinical records for Resident # 561 revealed an initial admission of [DATE] and readmitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 561 was ordered to receive 2 Liters (L) of oxygen (O2) per minute via nasal cannula as needed (PRN) for shortness of breath (SOB) based on order dated [DATE]. Record review of the Initial Minimum Data Set (MDS) revealed, Resident # 561 was coded for shortness of breath. Review of the Care Plan dated [DATE] revealed, Resident # 561 is at risk for altered respiratory status/difficulty breathing related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goals included that the resident would have less signs of shortness of breath through the review date. Target dated noted [DATE]. Interventions included, but were not limited to, oxygen 2 L per minute via nasal cannula as needed. On [DATE] at 12:28 PM the Nurse Manager revealed that Resident #561 is on PRN (as needed) oxygen and the resident's oxygen level should be checked by the nurse whenever they entered the room. During an interview and review of photographic evidence with Staff AA, a Licensed Practical Nurse (LPN) on [DATE] at 1:09 PM, Staff AA, LPN stated that Resident #561 is on oxygen PRN, and I checked it earlier this morning because he is going to be transferred to [NAME] now. Staff AA stated, that she did work on Monday and did not recall checking the oxygen level. Staff AA looked at the pictures and acknowledged the discrepancy. On [DATE] at 12:21 PM, the Director of Nursing (DON) was informed of the concerns related to Resident # 561's oxygen. The DON stated that the expectation is upon rounding the nurses are expected to ensure the oxygen is in place and at the correct level ordered by the doctor. 3) Observation on [DATE] at 10:16 AM revealed, Resident #99 has oxygen level at 3 Liters (L) with nasal cannula was in place. An observation on [DATE] at 10:48 AM revealed, Resident # 99 was in bed sleeping and the oxygen was on at 3 L and nasal cannula was out of the nose. An observation and interview on [DATE] at 10:51 AM with the Nurse Manager was conducted. The nurse manager reported the oxygen order is for 2 L continuous. The Nurse Manager proceeded to place the resident's nasal cannula inside the resident's nose. Record review of the order dated [DATE] revealed, place resident on O2 at 2 L/min (2 Liters per minute) continuous via NC (Nasal Cannula) every shift for shortness of breath and wheezing. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section O coded for oxygen and Section J coded for shortness of breath. Interview on [DATE] at 10:59 AM with Registered Nurse (RN) Staff A and the Unit Manager, revealed the resident was admitted to the hospital on [DATE] and came back to the facility on [DATE]th, 2021. Staff A, Registered Nurse (RN) reported the resident is on continuous oxygen at 2L per min. Interview with Staff C, a Certified Nursing Assistant (CNA) on [DATE] at 12:31 PM revealed, she is the resident's CNA and that the resident uses oxygen all the time. Staff C stated that if she observed the resident with the nasal cannula out of her nose she helps put it back on or tells the nurse. On [DATE] at 12:40 PM, the Nurse Manager revealed the resident was on continuous oxygen at 2 L. She reported, I conducted an in-service yesterday on [DATE] with the staff to monitor the oxygen and to follow the doctor's orders for the oxygen.

Based on record reviews, observations and interviews, the facility failed to ensure emergency equipment specifically portable suctioning machines and the wall suctioning system were adequately maintained and functioning in the event of an emergency. As evidenced by during an emergency the portable suction machine and the wall suction system was not functioning during Cardio Pulmonary Resuscitation (CPR) to help maintain a patent airway for Resident # 492 who had a copious amount of brown emesis in the mouth. The resident's diagnosis included difficulty swallowing which placed him at a high risk for aspiration and the resident subsequently expired. It was determined that this deficient practice posed Immediate Jeopardy (IJ) which is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was determined to be past noncompliance. The IJ started on [DATE] and the facility removed the immediacy on [DATE], the IJ was corrected on [DATE] when the re-education of staff had been completed. The findings included: Record review of the federal reported incident revealed, on [DATE] during breakfast time Certified Nursing Assistant (CNA) observed Resident # 492 nonresponsive and called the nurse to Resident # 492's room. The resident was not responsive to arousal and Cardio Pulmonary Resuscitation (CPR) was initiated. During CPR, a copious amount of brown emesis was noted in the resident's mouth, attempts were made to suction the resident but the suction machine that was delayed in arriving was not working when it was turned on and the wall suctioning system was not working. Emergency Medical Services arrived and the Automated External Defibrillator (AED) was used but the resident was nonresponsive and expired in the facility at 10:08 AM. Review of the clinical records revealed, Resident # 492 was admitted to the facility on [DATE] from a local hospital. Resident #492's Advance Directive revealed, the resident was a Full Code and cognitively intact. Clinical diagnoses included but were not limited to Cerebral infarction (or stroke), Dysphagia (difficulty in swallowing) and type 2 diabetes. Allergies documented were [MEDICATION(S)]. Review ofthe physician's orders revealed, Resident # 492 had an ordered dietary consult for a new admission, that was completed [DATE]. Review of the ordered diet with a start date of [DATE] documented: No Added Salt (NAS), pureed textured and nectar thicken liquids. Review of Resident # 492's breakfast meal ticket for [DATE] revealed standing orders for Mighty shake (no added sugar) honey thick and 6 ounces (Oz) super cereal puree. Dining location indicated, resident eats in room and no allergies noted. Resident # 492's required setup help only for eating. Review of the admission Minimum Data Set (MDS) revealed Resident # 492's required setup help only for eating. One person to physically assist with personal hygiene and for toileting two persons to physically assist. The resident was documented as being incontinent of bowel and bladder. The resident therapy services ordered included physical therapy, occupational therapy, and speech therapy. The baseline care plan indicated discharge plans initial goal was for Resident to return to the community and discharge location anticipated was to an assisted living facility with assisted living staff as caregivers. Review of a witness statement signed by former employee Staff DD, a Certified Nursing Assistant (CNA) noted, around 9:30 AM, when I entered resident (room #) the resident had his breakfast tray in front of him, vomit was on his bed and he was unresponsive. When I called him many times I immediately called the nurse. Attempts made to interview Staff DD, CNA by telephone on [DATE] and [DATE] was unsuccessful. Review of the nurse's notes created [DATE] at 08:37:04 by Staff EE, Licensed Practical Nurse (LPN) indicated: Resident continues on IVF (intravenous fluids), well tolerated, midline in place to left arm, patent, resident shows no signs of respiratory distress, no c/o (complain of) pain voiced. Resident started on [MEDICATION(S)] 500 MG (milligram) by mouth every 8 hours for Diverticulitis for 7 days, no adverse reaction noted, afebrile, PO fluid encouraged. Attempt x 1 to straight catheter to collect urine, no urine obtained, resident said that he just urinated, safety and comfort maintained, call light in reach, will continue to monitor. Report given to AM nurse to follow up . Discharge summary notes created by Staff FF, a Licensed Practical Nurse (LPN) on [DATE] at 14:28:06 :Rounds made this morning, Patient received in bed alert and oriented tiems 3, eyes open while TV is turned on. Writer said good morning sir, my name is {}, I will be your nurse this morning. Patient replies good morning, when is breakfast coming. writer observed patient with a peripheral IV running, site intact and patent. During breakfast time nursing aide called nurse to the room, patient observed non-responsive. When trying to arouse patient, patient refuses to wake up or answer. CPR initiate. CODE BLUE, and Program of All-Inclusive Care for the Elderly (PACE) Medical Doctor (MD) and nurses here to assist in CPR. 911 contacted, Fire rescue arrives to facility, 4 rounds of [MEDICATION(S)] given to arouse patient, not well tolerated. Constant suctioning of the patient in progress. All nursing interventions done on patient and patient continues to be non-responsive. Review of the physician's documentation dated [DATE] at 17:02:52 indicated {nurse manager name} myself at bedside providing CPR. Noted to have vomited brown emesis and had remnants in oropharyngeal airway. Patient suctioned as had a pulse, airways secured and ventilated via ambubag, and CPR administered, EMS arrived and patient was Shocked on PEA (Pulseless Electrical Activity) with AED (Automated External Defibrillator) and 4 rounds of epi, one sodium [MEDICATION(S)] before I called code at 10:08 am. On [DATE] attempts were made to contact the physician on the contact number received from the facility and attempts by telephone were unsuccessful. On [DATE] at 8:52 AM, the Director of Engineering and the Manager of Emergency Planning were asked who is responsible for the maintenance of the suction equipment. The Maintenance Manager stated that the high risk equipment is checked by a contracted service company that comes into the facility semiannually in May and November. The Director of Engineering explained, that high risk equipment is defined as the AED machines and based on the facility's internal judgement they added the suction machines were to the checked biannually. The wall systems however is checked by another contracted company. The Director of Engineering explained that when these companies come into the facility they are required to check 100% of the emergency equipment, an initial escort is done, it is possible but unlikely, we escort them we do not have to baby sit them, because the same individual comes for as long as I remember, they are the ones that put the green or blue stickers and it is dated but the electrical checks are done internally. Review of documents provided by the Director of Engineering and the Manager of Emergency Planning revealed, the contracted company completed inspections of the suction equipment between [DATE] to [DATE] and another inspection was completed by the same contracted company between [DATE] to [DATE]. There was no supporting documentation provided by the Director of Engineering nor the Manager of Emergency Planning on how the facility keeps track of the equipment and the specifics related to the machine that malfunctioned. Review of the invoice/Estimate dated [DATE]th, 2020 revealed: Aspirator, Suction, W 850 cc canister quantity 10, Aspirator, Suction, W 850 cc canister Rent to purchase/45.00 x 6-months-quantity 4 and Aspirator, Suction, W 850 cc canister quantity 1 -Teaching and education. Review of the documentation provided by the Director of Nursing, titled, New Suction Machine assignments; revealed 12 suction machines with units (Toppel South, etc) Managers names and serial # for each suction machine. Review of documentation provided by the Manager and Director of Engineering titled, Air compressor-Vacuum Pump Preventative Maintenance Service Report completed by the contracted company revealed on [DATE] an inspection was completed that included the vacuum pump system (wall suction) and another inspection was completed on [DATE] and noted checked box for quarterly PM (Preventative Maintenance). Review of Document provided by the Director of Nursing related to the suction machine that malfunctioned during the incident revealed the serial number and last inspection date noted as [DATE] inspection interval ;-365 days and next inspection date [DATE]. Further review of the inspection documents did not indicate information to indicate the contracted company had inspected the suction machine with the serial number noted on the preventative maintenance document provided. Record review for the inspections completed by the contracted company did not show documentation to indicate the new suction machines purchased [DATE] were tested during the [DATE] equipment inspection. Review of the facility's policy updated [DATE] titled, Medical Equipment Management Plan, revealed: Purpose-Medical equipment (used to treat, diagnose, or monitor patients) is a key component of medical treatment. The maintenance and repair of that equipment and staff training in use of that equipment is critical to maintaining safe and effective patient care. Technical management program : item 4- Measurements: Program measurements is done by the Preventive Maintenance Manager (PMM)/Supervisor, who oversees the contract personnel. The PMM reviews Preventative Maintenance logs on a monthly basis and makes periodic observations and rounds. 5. Criteria are used to determine which equipment is included in the Medical Equipment Management System. Equipment is generally maintained by contract. Corrective actions (equipment repair) is the responsibility of the Engineering and Maintenance Department, either by use of their staff, or by contract with manufacturers or specialty repair contractors. Process: Reporting and documenting problems: 1. Equipment malfunctions or equipment damage: Equipment damage or malfunctioning equipment is reported to engineering and maintenance. Routine incidents (with no patient care implications) are handled by calling the Engineering and Maintenance Department for repair . Any incident which has an impact or potential impact on patient care or safety is documented by an incident report and sent to Risk Management. On [DATE] at 9:10 AM, during an interview with the Director of Nursing and the Vice President of Clinical Services. The DON stated, the incident happened during breakfast and the staff had set up the resident's tray and when they returned they noticed he was unresponsive. The resident received his tray between 9:30 AM and 9:45 AM and CNA found him between 9:30 am and 9:45 am. The DON revealed, the resident was diabetic but did not have any orders for blood sugar checks and was able to feed himself and that the resident was a full code. The nurse that worked, was an agency nurse. I was the reporter of the incident; I received the allegation on [DATE] in the morning the allegation came from the physician that was present during the incident. The doctor reported that she was concerned that during the code blue she did not have a suction machine and she could have saved the patient if she had the suction machine. We did an extensive investigation; we interviewed all the staff involved. The nurse manager, the nurse and the CNA that observed the resident was not involved in the code blue and the Advanced Registered Nurse Practitioner (ARNP), the nurse manager and the physician no longer work with our facility also the CNA is no longer employed with us. We interviewed everyone present during the incident and we found that we did not have the suction machine readily available and it was not clear that even if we had a suction machine readily available and working if we would have saved the patient because we used other measures such as, turning the resident to the side, suction with the syringe and we were able to suction the emesis that was in the mouth with the syringe. The DON and Vice President of Clinical Services was asked if the resident should he have been suctioned, the DON stated it was not the practice for CPR, but because the physician was present at the time the resident would be suctioned. The expectation would be to perform basic CPR which did not include suctioning a patient. The criteria for suctioning would be if the patient were in the dining room choking or during a mealtime if the resident is having a snack and when the resident is noted to be breathing and observed to be choking, a licensed nurse can perform suctioning. Suctioning is performed with a physician order for excessive secretion and only the licensed nurse can perform suctioning. The DON revealed, that the facility currently does not have any residents that require suctioning. The Ambu bag was used to clear the airway which is our best practice and what we teach during CPR because we are not a hospital. During the time of the code, we called 911 that was the first thing we did. The paramedics did shock the resident with the AED and 4 rounds of epi sodium [MEDICATION(S)] because the physician insisted. The time of death was 10:08 pronounced by the fire rescue. The DON stated, she does not have the time the CPR was started by the facility staff, but she has a copy of statements and interviews. The DON reported, a root cause analysis was done when the case was closed on [DATE], the DON stated, we found that we have areas of improvement such as the availability of equipment and supplies during the code. But we practice basic life support which is the expectation that we have for our nursing staff suctioning a patient during CPR was not part of our best practice, the policy was revised for CPR after the incident in [DATE]. The DON reported, the suction machine that was used came from 2 [NAME] and found out later on that it was working but no one knows why it was not working at that time of the incident. The DON stated, Either way we ordered fifteen new suctioning machines they were ordered on [DATE]. The DON revealed that the corrective actions that the facility implemented after the incident include: All suction machines were checked on [DATE], and the 15 additional suction machines were ordered and were provided to each unit, checklist will be updated to allow nurses to check crash carts and suction machines. Suction machines are checked for proper functioning daily by the unit nurse and weekly by the nurse manager. Audits were submitted to Quality department on a weekly basis and discrepancies evaluated for 2 months and after that the nurse managers are responsible to check weekly. Ongoing education provided to the nursing staff on how to properly work the suction machines and a competency check was completed. Additionally, all Crash Carts and keys were checked on [DATE]. The Crash carts will continue to be checked daily by the nurse, weekly by nurse managers and audits will also be submitted to the quality department for evaluation on an ongoing basis. The Code blue policy was updated to assure that the roles and responsibilities are clearly defined, education was provided to all Nursing staff on the new process and a quality tools developed to evaluate all code blue events. The DON reported, that the nurses were educated on the suctioning machine and best practice during code blue or patient assessment team call which is the facility's internal process. The DON stated, I did the training myself mock Code Blue in different sessions. The DON explained the trainings were done in the facility's auditorium and set up was as if they were in a patient's room and with return demonstration by all nursing staff. All the nurses and CNAs are required to have CPR training. If a CNA is in a room and notices a resident nonresponsive the CNA can start BLS (Basic Life Support) and call the nurse. Anyone can call a PAT (Patient Assessment Team) or code blue an internal response system is on the badges (copy requested) they call 222 and begin BLS which includes calling for help checking if resident is a DNR (Do Not Resuscitate) or full code if full code initiate CPR. The resident was full code. The DON explained, the facility's policy during a code; there is a team leader, the ARNP would be the lead and delegate the task to the team. If the ARNP is not present the supervisor or nurse manager will assume the lead. When a CNA identifies an issue, they are required to get the nurse and the nurse goes into the room. On [DATE] at approximately 11:40 AM the Administrator (NHA), revealed the licensed nurses, the CNAs and all staff are held at a higher standard. The integrity of the staff and expectations are that we have a job to do and there are going to be incidents and nobody should sweep it under the rug whether good or bad. Risk is the most serious thing in this organization and the continuing education on what is reportable and as the NHA he wants to be notified of all incidents. I rather hear about it immediately. The NHA stated that the facility is required to take care of the resident because the family entrust the care on the facility. The NHA explained that he was not made aware of the incident until the next day, on [DATE] was when the doctor informed the DON of the incident and raised the questions during the morning meeting about the code and when the concerns were explained by the doctor the DON called in the report. The NHA revealed, that he was concerned that he was not informed until the following day and the CEO (Chief Executive Officer) was also involved because no one mentioned it or reported anything until the doctor mentioned the concerns in the morning meeting the day after the incident instead of at the point in time when the incident occurred, because it could have been reported earlier and it is part of the facility's Quality Assurance and Improvement (QAPI).The NHA stated, that he did not consider the incident an adverse incident. Review of the local fire department's ambulance run report narrative revealed, on [DATE] at 9:49 AM , male found at scene unresponsive. Patient (Pt) was found to be asystole. CPR was initiated continued for 30 minutes. Pt remained in asystole for the duration of the [CONDITION(S)]. Pt was pronounced dead in the field and Dr (doctor name and license) agreed with the crew's decision. Local police department was notified. Review of the facility's Patient Assessment Team (PAT) procedure with effective date [DATE] and revision date ,d+[DATE] indicates: Procedure: The Patient Assessment Team (PAR): a. can be activated by all healthcare personnel who provide patient care in the facility. b. Does not require a physician's order or permission. c. Activate the PAT call by calling the EXT. 222. 2. The patient assessment team shall be composed of a ARNP-PAT Leader, responsible for designating roles and responsibilities, assessing the resident/situation. B. Nurse responsible for gathering the resident's medical history (i.e., chart) and or any task delegated by the PAT Caller leader. C. Manager /Supervisor - Assist the ARNP with maintaining order and or task assign by the PAT Call leader, and will complete tasks delegated by PAT leader d. CNA - Will complete task delegated by the PAT leader e. Respiratory Therapist-If available will assist the PAT team with CPR and / or any tasks delegated by the PAT leader. G. Physician- if available, will provide guidance/support to the PAT leader. 3. The Patient Assessment Team will be called to provide further evaluation for, but not limited to the following conditions: a. change in airway stability, b. Symptomatic change in respiratory status. C. Sudden change in oxygenation (O2 saturation below 90). D. Sudden change in level of consciousness or mental status. e symptomatic change in heart rate. 7. The ARNP or PAT call leader with guidance of the physician if available, will determine if the patient's medical status warrants treating in place, transfer to [NAME] Gardens Hospital, activating a Code Blue and /or transfer to an outside hospital via 911 . Review of the facility's policy titled, Code Blue (nursing Home) effective date ,d+[DATE] and revision date [DATE]. Purpose: to summon the Basic Life Support (BLS) team to cardiopulmonary arrest in progress. To initiate immediate and appropriate intervention in life threatening emergencies. Procedure: If the resident is not DNR (Do Not Resuscitate), is not breathing and /or is without a pulse, 911 will be called and CPR will be initiated. 2. Available personnel will activate the emergency call system by dialing 222 and request a Code Blue. The name of the resident, unit and room number will be provided to the dispatcher, who will then overhead page the location and room number provided. 3. The personnel performing the CPR will continue until all Code Blue Team members are present and or is instructed by code leader. Code Blue Team members are as follows: ARNP- Code leader, responsible for designating roles and responsibilities, assessing the resident/situation. Roles and responsibility: The code leader will clearly and firmly define each member's roles and responsibilities during the code including but not limited to: Bringing the emergency cart (backboard, Ambu bag) Bringing AED, Bringing oxygen, gathering medical history, switching roles during CPR, contacting family and code outcome. 6. At the end of the code, the code leader will complete a Code Blue Evaluation Tool, that will evaluate the code, tool will be submitted to the Quality department. On [DATE], the survey team concluded verification of the corrective actions implemented by the facility through conducted observations of the suction machines to ensure they are working and observation of crash carts location and items, also other information noted in the corrective actions were verified through staff interviews and record reviews. The facility's corrective actions included: Suction Machine 1. Check all suction machines by nurse managers [DATE]. 2. New suction machine for 2 M was ordered and arrived functioning properly on [DATE]. 3. Fourteen (14) additional machines were ordered from foster medical. 4. New checklist to allow nurses to check crash cart and suction machine developed. 5. Nurses will in-serviced and have a competency check on using suction machine. 6. Suction machines will be checked for proper functioning daily by the unit nurse, weekly by the nurse manager, biweekly. 7. Audits will be submitted to Quality on a weekly basis by Friday 5 pm, any discrepancies will be evaluated. Crash Cart 1. Crash carts were checked on [DATE] 2. Keys to all crash carts will be distributed to all nurses' key rings, ARNPs, key MJH physicians nurse managers and supervisors. 3. Crash cars will continue to be checked daily, weekly by nurse managers. Audit will be submitted to QAPI on a weekly basis on Friday 5 pm X 3 months. 4. Crash carts will be checked for supplies daily. Code Blue 1. Code blue policy will be updated to assure that the roles and responsibilities are clearly defined. 2. Education will be provided to all nurses, Nurse managers and all related staff on the new process. 3. ARNPs will perform mock codes with the support of education. 4. A quality tool completed by the leader of the code will be completed and scanned over to quality.

Based on interview and record review, the facility failed to provide appropriate supervision to prevent a fall resulting in actual harm for 1 (Resident #1) out 3 sampled residents reviewed for falls. Resident #1 fell out of bed which resulted in nose and facial fractures requiring hospitalization , intubation, and surgical repair. Cross reference to F282. The findings included: Record review of the resident face sheet revealed, resident # 1 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) for resident # 1 dated 12/1/15 revealed, resident #1's Brief Interview for Mental Status (BIMS) score was 0, meaning severe cognitive impairment. Bed mobility was coded as total dependence with 2+ persons physical assist. The resident's ability to transfer was coded as extensive assistance with 2+ persons physical assist. Locomotion on unit (how resident moves between locations in room) was coded total dependence with one person physical assist. Toilet use (cleanses self after elimination) was coded as total dependence, and 2+ persons physical assist. Bathing self-performance was coded as total dependence. Bathing support provided was coded as two person physical assist. Record review of the Morse fall scale for resident # 1 dated 6/16/15 revealed, a score of 65 indicating high risk for falls. (Morse fall scoring ledger: High risk 45 and higher, moderate risk 25 to 44 and low risk 0 to 24). Record review of the Morse fall scale for resident # 1 dated 12/22/15 revealed, a score of 55 indicating high risk for falls. Record review of resident #1's falls care plan initiated 12/22/15. Focus: The resident is at risk for falls related to previous fall history, fall risk factors s/p (status [REDACTED]. Sent to hospital. On 1/14/16 re-admit resident with high risk for falls and injury related to new environment, poor safety awareness, limited mobility, incontinence, disease process and hearing ability. Interventions included, Assist with all her ADLs. PDA present as scheduled. Observe for resident placing her legs over the side of bed. Reposition as needed. Provide frequent supervision. Low bed with bedside mats. Record review of the nurse's notes for resident # 1 dated 12/22/15 fall note revealed, At 13:15 (1:15PM) called to resident's room by private duty aide (PDA) stating resident had a fall, resident was lying on floor on her back with bleeding laceration to her nose, ice pack applied, resident continued to have continuous bleeding from nose and spitting blood from her mouth, patient assessment team (PAT) team called. Resident continued to have bleeding and 911 was called at 13:20 (1:20PM). Ice pack continued to be applied. Resident was combative and spitting at staff. Resident was changed. Assistant Director of Nurses (ADON) gave emotional support, as well as ice to laceration, bleeding slowed and coagulation noticed as emergency personnel arrived on the unit, medical doctor called, guardian called and notified. At 13:38 (1:38PM) resident transferred via 911 ambulance to hospital. Record review of the medical doctor (MD) telephone order for resident # 1 dated 12/22/15 revealed, discharge to hospital via 911. Record review of the facility's fall policy revised 10/2014 revealed, Fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Falls can be a source of serious injuries to residents. The facility will take steps to reduce the number and severity of falls by establishing a framework for assessing risk factors contributing to falls, reduce the risk for falling and protect residents from fall-related injuries and conduct appropriate post fall assessments, communication and proactive interventions. Phone interview on 2/10/16 at and 10:39 am with certified nursing assistant A (CNA A) revealed, on 12/22/15 she had just finished cleaning resident #1 in bed. The private duty aide, who was watching resident #1, left the room to attend to private matters. CNA A confirmed that she cleaned resident #1 by herself. CNA A then stated, she went to the bathroom and when she returned, resident # 1 was on the floor. CNA A noted, she cleaned resident #1 by herself, since the private duty aide left the room prior to her cleaning resident #1. Interview on 2/10/16 at 3:58 pm with the Director of Nursing (DON), Assistant Director of Nursing (ADON, staff B), Director of Social Services and Risk Manager regarding resident #1 revealed, the date of the incident was on 12/22/15 and took place in the early afternoon. The ADON stated, she was working on the day of the incident on 12/22/15 and noted, the patient assessment team (PAT) was called. Resident # 1 had a low bed and was being attended to by staff. The ADON stated, she saw a laceration to the bridge of the nose and there was active bleeding from this site for resident #1. The ADON stated, she thought the nose for resident # 1 might be fractured at that time, however there was no swelling to the face and no bruising at that time. The ADON said, resident #1 was alert and verbally responsive and ice was applied. The ADON noted, resident # 1 was agitated and vital signs were taken. The ADON reported, fire rescue was called due to active bleeding. The ADON stated, CNA A was working the 7 am to 3 pm shift and resident # 1 also had a private duty aide (PDA). The ADON noted, the bed for resident # 1 did not have side rails but was a low bed. The ADON mentioned, resident # 1 was sent to the hospital per the medical doctor's order. The DON, ADON, director of social services and risk manager then noted, per their investigation they interviewed CNA A. She stated, she was changing resident #1's clothes and adult briefs since she had a bowel movement at that time. According to her, the private duty aid was in the room. After she changed resident # 1 CNA A went to the bathroom to dispose of the adult brief, wash the basin and wash her hands. The DON, ADON, director of social services and risk manager stated, CNA A said that when she left resident # 1, the private duty aide was there with resident # 1. The DON, ADON, director of social services and risk manager then noted, CNA A told them she was in the bathroom when she heard the private duty aide mention she would go the bathroom and the private duty aide walked out of resident #1's room. The DON, ADON, director of social services and risk manager then said that CNA A reported to them, she went to the bath room, heard a crash sound while she was in the bathroom. CNA A came out and found resident # 1 face down on the floor bleeding. CNA A then called for help. CNA A called the nurses. The nurses were the first to assist. The nurses were nurse C and nurse D. Nurse C and nurse D entered the room and resident # 1 was face up but still on the floor. CNA A told them she turned resident # 1 over to check her since she was bleeding. The DON, ADON, director of social services and risk manager noted, they interviewed the private duty aide who stated, she was not in the room to assist in cleaning resident # 1 and that she left CNA A with resident # 1 because she had to go to the bathroom. The private duty aide told the facility members, when she came back, CNA A said resident # 1 fell on the floor. The Private duty aide, told the facility staff members, she looked in the room and saw resident # 1 on the floor bleeding. The DON, ADON, the director of social services and risk manager noted that there were inconsistencies with both CNAs stories. The DON, ADON, the director of social services and risk manager concluded, the bed for resident # 1 was not in the lowest position when the nurses came to help and saw the bed for resident # 1 in a higher position for the low bed. The DON, ADON, the director of social services and risk manager noted that there were safety concerns with the CNAs leaving resident #1 with safety measures not in place since the bed should have been in the lowest position and was not. The floor mat was not at the side of the bed for resident #1. Initially the facility members concluded it was an accident, but upon further investigation the family of resident #1 had pictures of resident # 1 with black and blue swollen areas around the eyes. These photos were taken in the hospital by resident #1's family. The ADON noted, resident #1 was on the medication Plavix, this medication can cause the resident to hemorrhage/bleed. The DON, ADON/staff B, the director of social services and risk manager noted, due to the conflicting stories of both CNAs, the safety measures were not followed. Resident # 1 should not have been left alone and the floor mat was not at the side of the bed. The DON, ADON staff B, the director of social services and risk manager (facility members) concluded, there was a lack of supervision on the part of CNA A and confirmed this to the surveyor. The facility members stated that they did not consider this negligence, but poor judgment since CNA A left the private duty aide at the bed side. The facility staff members at first noted that CNA A should have used two CNAs to clean resident # 1 according to the care plan for two person assist. The facility staff members then said, the ADL care plan for resident #1 documents two person assist and it could be a staff cna and a private duty aide. The DON, ADON, the director of social services and risk manager confirmed, the CNA A did not follow the care plan of the facility for two person assist for changing resident # 1. The DON, ADON staff B, the director of social services and risk manager then later said that CNA A reported, the private duty aide was assisting her and the private duty aide stated, she did not assist CNA A. The facility staff members stated, both of the CNAs were terminated due to the conflicting stories. Record review of the hospital record for the Computerized Tomography (CT-diagnostic test) revealed, a CT of the maxillofacial area without contrast dated 12/22/15 for resident # 1 with an impression: Complex fractures of the facial bones, comminuted fracture of the nasal bones, nasal pillar and nasal septum, le fort fracture (fracture of the midface). Isolated fracture right orbital rim and anterior lateral wall of the right maxillary sinus. Record review of the hospital physician progress notes [REDACTED]. Patient agitated, unable to protect her airway. Will proceed to intubate the patient. Patient currently on mechanical ventilation. Will transfer to intensive care unit (ICU). Pending facial surgery consult. MD consulted and accepted consult for facial bone fracture.

Based on interview and record review, the facility failed to follow the care plan for activities of daily living (ADL) for providing appropriate toileting care with a two person assist resulting in actual harm for 1 (Resident #1) out of 3 sampled residents reviewed for care plans. Resident #1 fell out of bed which resulted in nose and facial fractures requiring hospitalization , intubation, and surgical repair. Cross reference to F323. The findings included: Record review of the resident face sheet revealed, resident # 1 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) for resident # 1 dated 12/1/15 revealed, resident #1's Brief Interview for Mental Status (BIMS) score was 0, meaning severe cognitive impairment. Bed mobility was coded as total dependence with 2+ persons physical assist. The resident's ability to transfer was coded as extensive assistance with 2+ persons physical assist. Locomotion on unit (how resident moves between locations in room) was coded total dependence with one person physical assist. Toilet use (cleanses self after elimination) was coded as total dependence, and 2+ persons physical assist. Bathing self-performance was coded as total dependence. Bathing support provided was coded as two person physical assist. Record review of the Morse fall scale for resident # 1 dated 6/16/15 revealed, a score of 65 indicating high risk for falls. (Morse fall scoring ledger: High risk 45 and higher, moderate risk 25 to 44 and low risk 0 to 24). Record review of the Morse fall scale for resident # 1 dated 12/22/15 revealed, a score of 55 indicating high risk for falls. Record review of the Activities of Daily Living (ADL) care plan for resident #1 initiated on 12/22/14 and revised on 12/22/15 and 02/09/16 revealed, problem: (Resident #1) has a self care deficit, needs total assistance with all areas of her ADLS, toilet use and bathing related to her disease process, poor motivation, mood/behavior, cognitive impairment, balance and coordination. Interventions: Provide assistance of 2 persons with bathing, hygiene, incontinent care and transfers. Record review of resident #1's falls care plan initiated 12/22/15. Focus: The resident is at risk for falls related to previous fall history, fall risk factors s/p (status [REDACTED]. Sent to hospital. On 1/14/16 re-admit resident with high risk for falls and injury related to new environment, poor safety awareness, limited mobility, incontinence, disease process and hearing ability. Interventions included, Assist with all her ADLs. PDA present as scheduled. Observe for resident placing her legs over the side of bed. Reposition as needed. Provide frequent supervision. Low bed with bedside mats. Record review of the nurse's notes for resident # 1 dated 12/22/15 fall note revealed, At 13:15 (1:15PM) called to resident's room by private duty aide (PDA) stating resident had a fall, resident was lying on floor on her back with bleeding laceration to her nose, ice pack applied, resident continued to have continuous bleeding from nose and spitting blood from her mouth, patient assessment team (PAT) team called. Resident continued to have bleeding and 911 was called at 13:20 (1:20PM). Ice pack continued to be applied. Resident was combative and spitting at staff. Resident was changed. Assistant Director of Nurses (ADON) gave emotional support, as well as ice to laceration, bleeding slowed and coagulation noticed as emergency personnel arrived on the unit, medical doctor called, guardian called and notified. At 13:38 (1:38PM) resident transferred via 911 ambulance to hospital. Record review of the medical doctor (MD) telephone order for resident # 1 dated 12/22/15 revealed, discharge to hospital via 911. Phone interview on 2/10/16 at and 10:39 am with certified nursing assistant A (CNA A) revealed, on 12/22/15 she had just finished cleaning resident #1 in bed. The private duty aide, who was watching resident #1, left the room to attend to private matters. CNA A confirmed that she cleaned resident #1 by herself. CNA A then stated, she went to the bathroom and when she returned, resident # 1 was on the floor. CNA A noted, she cleaned resident #1 by herself, since the private duty aide left the room prior to her cleaning resident #1. Interview on 2/10/16 at 3:58 pm with the Director of Nursing (DON), Assistant Director of Nursing (ADON, staff B), Director of Social Services and Risk Manager regarding resident #1 revealed, the date of the incident was on 12/22/15 and took place in the early afternoon. The ADON stated, she was working on the day of the incident on 12/22/15 and noted, the patient assessment team (PAT) was called. Resident # 1 had a low bed and was being attended to by staff. The ADON stated, she saw a laceration to the bridge of the nose and there was active bleeding from this site for resident #1. The ADON stated, she thought the nose for resident # 1 might be fractured at that time, however there was no swelling to the face and no bruising at that time. The ADON said, resident #1 was alert and verbally responsive and ice was applied. The ADON noted, resident # 1 was agitated and vital signs were taken. The ADON reported, fire rescue was called due to active bleeding. The ADON stated, CNA A was working the 7 am to 3 pm shift and resident # 1 also had a private duty aide (PDA). The ADON noted, the bed for resident # 1 did not have side rails but was a low bed. The ADON mentioned, resident # 1 was sent to the hospital per the medical doctor's order. The DON, ADON, director of social services and risk manager then noted, per their investigation they interviewed CNA A. She stated, she was changing resident #1's clothes and adult briefs since she had a bowel movement at that time. According to her, the private duty aid was in the room. After she changed resident # 1 CNA A went to the bathroom to dispose of the adult brief, wash the basin and wash her hands. The DON, ADON, director of social services and risk manager stated, CNA A said that when she left resident # 1, the private duty aide was there with resident # 1. The DON, ADON, director of social services and risk manager then noted, CNA A told them she was in the bathroom when she heard the private duty aide mention she would go the bathroom and the private duty aide walked out of resident #1's room. The DON, ADON, director of social services and risk manager then said that CNA A reported to them, she went to the bath room, heard a crash sound while she was in the bathroom. CNA A came out and found resident # 1 face down on the floor bleeding. CNA A then called for help. CNA A called the nurses. The nurses were the first to assist. The nurses were nurse C and nurse D. Nurse C and nurse D entered the room and resident # 1 was face up but still on the floor. CNA A told them she turned resident # 1 over to check her since she was bleeding. The DON, ADON, director of social services and risk manager noted, they interviewed the private duty aide who stated, she was not in the room to assist in cleaning resident # 1 and that she left CNA A with resident # 1 because she had to go to the bathroom. The private duty aide told the facility members, when she came back, CNA A said resident # 1 fell on the floor. The Private duty aide, told the facility staff members, she looked in the room and saw resident # 1 on the floor bleeding. The DON, ADON, the director of social services and risk manager noted that there were inconsistencies with both CNAs stories. The DON, ADON, the director of social services and risk manager concluded, the bed for resident # 1 was not in the lowest position when the nurses came to help and saw the bed for resident # 1 in a higher position for the low bed. The DON, ADON, the director of social services and risk manager noted that there were safety concerns with the CNAs leaving resident #1 with safety measures not in place since the bed should have been in the lowest position and was not. The floor mat was not at the side of the bed for resident #1. Initially the facility members concluded it was an accident, but upon further investigation the family of resident #1 had pictures of resident # 1 with black and blue swollen areas around the eyes. These photos were taken in the hospital by resident #1's family. The ADON noted, resident #1 was on the medication [MEDICATION NAME], this medication can cause the resident to hemorrhage/bleed. The DON, ADON/staff B, the director of social services and risk manager noted, due to the conflicting stories of both CNAs, the safety measures were not followed. Resident # 1 should not have been left alone and the floor mat was not at the side of the bed. The DON, ADON staff B, the director of social services and risk manager (facility members) concluded, there was a lack of supervision on the part of CNA A and confirmed this to the surveyor. The facility members stated that they did not consider this negligence, but poor judgment since CNA A left the private duty aide at the bed side. The facility staff members at first noted that CNA A should have used two CNAs to clean resident # 1 according to the care plan for two person assist. The facility staff members then said, the ADL care plan for resident #1 documents two person assist and it could be a staff cna and a private duty aide. The DON, ADON, the director of social services and risk manager confirmed, the CNA A did not follow the care plan of the facility for two person assist for changing resident # 1. The DON, ADON staff B, the director of social services and risk manager then later said that CNA A reported, the private duty aide was assisting her and the private duty aide stated, she did not assist CNA A. The facility staff members stated, both of the CNAs were terminated due to the conflicting stories. Record review of the hospital record for the Computerized Tomography (CT-diagnostic test) revealed, a CT of the maxillofacial area without contrast dated 12/22/15 for resident # 1 with an impression: Complex fractures of the facial bones, comminuted (reduced to small particles) [MEDICAL CONDITION] bones, nasal pillar and nasal septum, le fort fracture ([MEDICAL CONDITION]). Isolated fracture right orbital rim and anterior lateral wall of the right maxillary sinus. Record review of the hospital physician progress notes [REDACTED]. Patient agitated, unable to protect her airway. Will proceed to intubate the patient. Patient currently on mechanical ventilation. Will transfer to intensive care unit (ICU). Pending facial surgery consult. MD consulted and accepted consult for facial bone fracture.

Based on observation, interview, and record review, the facility failed to minimize or prevent pain for two (Resident #1, #2) of four residents identified for end of life care. This failure to provide the necessary assessment and pain medication resulted in the residents experiencing ongoing pain without relief. In addition, based on record review and interview, the facility failed to provide necessary nursing care and services for 1 (Resident #11) of 3 residents sampled for injuries of unknown origin, by not reporting and documenting the resident's injuries immediately to the appropriate facility staff. The findings include: 1) Review of the Admission Record of Resident #1 revealed, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Physician order [REDACTED]. Review of the Physician Telephone Order dated 12/23/14 revealed a physician order [REDACTED]. During observation of resident #1 on 12/22/14 at 11:50am revealed, the resident was lying in bed on her right side. During this observation on 12/22/14 at 11:50am, the resident complained of pain to her body and back-side. The resident reported, she fell at home. During observation of resident #1 on 12/23/14 at 5:48pm, the resident reported, she felt bad with pain in her hip, stomach and chest and she felt weak. At this time, the nurse came into the room to give the resident a breathing treatment and the resident requested something for pain. Review of the Medication Administration Record [REDACTED]. Review of the medical record revealed, a Pain assessment dated [DATE]. The form documented, the resident had no pain. There were no other pain assessments in the medical record. During interview on 12/23/14 at 6:07pm with the Assistant Director of Nursing (ADON) revealed, the residents were assessed for pain during the nurses rounds and the nurses looked for nonverbal signs of pain, and if the signs were present, they would do pain assessment on the resident. The ADON, asked the supervisor to do a pain assessment for resident #1 immediately and to give the resident something for pain. Interview on 12/24/14 at 10:57am with the Wound Care nurse revealed, "the resident is not routinely medicated before wound care, but the resident has never complained of pain during the wound care procedure. The resident receives pre-medication for pain if the resident complains of pain during the treatment, and he would stop the treatment and get order for pain medication prior to treatment again." Duirng interview on 12/24/14 at 12:30pm with the Advanced Registered Nurse Practitioner (ARNP), who examined resident #1 during a palliative consult dated 12/15/14, it reported, during the examination, the resident complained of generalized and sacral pain. The ARNP reported, the resident had verbal and non-verbal indicators of pain during the examination. She reported, the resident was hard of hearing and blind in one eye and had a history of [REDACTED]. She also had a Foley catheter. She indicated, she spoke with the staff after the exam to let them know the resident had pain during the exam and wrote a recommendation for her to receive Tylenol around the clock for pain. She stated, in her professional opinion, the resident needed the medication for comfort. During the review of the Minimum Data Set (MDS) with an assessment reference date of 11/17/14, it was noted Section J was coded for no pain. This meant that in the 7 days prior to that date, Resident #1's pain was not assessed as present during that period. Review of the Comprehensive Care Plan for Resident #1 revealed, "Resident at risk for pain r/t disease process: History of [MEDICAL CONDITION] with [MEDICAL CONDITION], stage 3 sacral ulcer. Goal: Resident will not have discomfort related to side effects of [MEDICATION NAME] through the next review; Resident will not have an interruption in normal activities due to pain through the review date. Interventions: Administer [MEDICATION NAME] as per orders. Give ? hour before treatments or care, position resident for comfort, identify area of discomfort. Assess for pain and relief post interventions, anticipate the resident's need for pain relief and respond immediately to any complaint of pain." 2. Review of the Admission Record of Resident #2 revealed, was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Physician order [REDACTED]. Review of the 11pm-7am (11-7) nurses' note for resident #2 dated 10/31/14 at 3:38am revealed, the resident complained of generalized pain and was medicated once for pain with good effects. There was no pain assessment or pain assessment scores in the note. At 6:39am the note documented, the resident spent most of the night screaming out. There was no pain assessment was completed and there were no other interventions documented for the residents pain and comfort. During interview on 12/24/14 at 11:18am with LPN-B from the 11-7 shift it was revealed, Resident (#2) began to yell and she was assessed for pain by asking the resident if she was in pain. She stated, she was in pain and Tylenol was given. The resident continued to yell, but when asked if she was in pain, she stated that she had no pain. She confirmed, there was no pain assessment or pain assessment scores documented in the nursing note. Interview on 12/24/14 at 1:05pm with LPN-C from the 3pm-11pm shift, it was revealed, resident #2 complained of pain and was medicated with Tylenol. She confirmed, no pain assessment was done to determine the resident pain intensity or pain scale score. Review of the Comprehensive Care Plan dated 10/24/14 for Resident #2 revealed, "Resident has potential for pain and discomfort related to her disease process; History of fall with fracture. Goal: The resident will verbalize adequate relief of pain through the review date. Interventions: Notify MD/ARNP if no pain relief, Monitor for pain every shift, maintain comfort measures; evaluate the effectiveness of pain interventions, impact on functional ability and impact on cognition." Review of the facility's policy titled, "Pain Management" dated 07/1999 revealed, "The identification and treatment of [REDACTED]. Pain intensity and relief must be assessed each time vital signs are taken. Pain is considered the fifth vital sign; Pain intensity is measured with the appropriate measurement tool. A numerical pain scale of 0-10 (0=no pain, 10=worst pain) is utilized for adult residents. If they cannot understand or unwilling to use the scale, the Wong-Baker faces pain scale (smile-frown) is utilized; Pain monitoring: 1. Assess all residents for pain each time the vital signs are taken. Complete a pain Assessment form for new pain." Reference F282 3) Record review of the resident #11's clinical chart revealed, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the facility's 2014 log for injuries of unknown source revealed R#11 was listed on the report with an allegation dated 09/22/14. Record review of the facility's report revealed, the date and time of the incident was on 09/22/14 at 7:10AM. A description of the incident was documented as: "resident (#11) was observed by assigned aide with a discoloration to right thumb/hand which was also noted to be swollen. Resident is unable to state how discoloration happened when asked. Review of attached written statements from the staff revealed staff FF (certified nursing assistant (CNA) working on 09/20/14 and 09/21/14) did not notice anything on the resident's hand on 09/20/14; but on 09/21/14 she saw a discoloration on the resident's right hand and reported it to the nurse. Written statement from staff GG (licensed practical nurse (LPN)) revealed she was called by the CNA to the room, a dark blue discoloration noted in the right thumb, and she applied ointment to the area." Record review of nurses notes dated 09/12/14 to 09/22/14 revealed, no documentation was made on 09/20/14 or 09/21/14 about the injury. The nurses notes dated 09/22/14 revealed, the LPN was informed by the CNA that the resident had a discoloration to the right hand, on observation the resident was noted with discoloration to right hand and area also noted to be swollen, resident is unable to state how discoloration happened when asked. The Manager and resident's family member was made aware. The advanced registered nurse practitioner (ARNP) assessed area and an x-ray to the right hand was ordered. Record review of the resident's care plans revealed, a care plan on file for impaired skin integrity related to (risk/actual) trauma wound, pressure ulcer, vascular wound, unavoidable condition i.e. hospice, noncompliant, initiated on 11/05/13. Interventions to include but not limited to assess for skin intactness, report to the doctor (MD)/advanced nurse practitioner(ARNP) as indicated. Interview with staff CC (registered nurse, manager of clinical nursing for Chernin 2nd and 3rd floor) on 12/23/14 at 3:14PM revealed, on 9/22/14 she was informed by the nurse that R#11's CNA had reported a discoloration to the resident's right hand. She went to the room to assess the resident and saw the discoloration, the resident told her to leave her alone and get out. The resident's practitioner was called as well as the responsible party. The doctor ordered an x-ray; the x-ray results documented the resident did not have any fractures or dislocations. The resident remained in the facility. When asked, what the procedure is when the nurse reports to her a change in the resident's condition, she said she goes to the room and does her own assessment, she asks the resident to tell her what happened, makes sure the orders are carried out and that the nurse called the family and the resident is monitored for any change in condition. She talks to the nurse on the next shift to make sure they are following up and carrying out the orders given. She does not input anything in the system. Interview with staff EE (licensed practical nurse, resident #11's assigned nurse) on 12/23/14 at 3:33PM revealed, on 9/22/14, CNA DD reported to her that the resident had a bruise on her right hand. She went and observed the resident, she had a bruise on her right hand, it was swollen, no bleeding observed. She made the manager (staff CC) aware and called the resident's family and notified the ARNP. A right hand x-ray was ordered. No dislocations, no fractures were identified on the x-ray. She explained, if she notices a change in condition in a resident she goes and assesses the resident, observes, and asks the resident if they know what happened, she also questions the CNA. If the previous shift was there, she asks the previous shift. She notifies the manager or the supervisor, ARNP, doctor, family member and carries out the orders from the doctor. She goes in the system and writes exactly what happened, what was found, how it looked, sends notification to the MD and family, orders given and how the resident was. She also fills out a report in the system. Interview with staff FF (CNA 3-11 shift) on 12/23/14 at 3:58PM revealed, she acknowledged she wrote the written statement. On Sunday 09/21/14, she observed a discoloration on the resident's right hand and she informed staff GG. Interview with staff GG (LPN) on 12/23/14 at 4PM revealed, on 9/21/14, staff FF (CNA) informed her of the resident's hand, she went in the room and assessed the resident. The resident told her she was not in pain. The LPN explained, she applied Zinc oxide to the right thumb which was blue at the time. She helped the CNA change the resident. The LPN said, she was supposed to document in the nurses notes because this was a change in the resident's condition, and inform the doctor and the family. She reported, she did not write a note, report, call the doctor, or the resident's family.

Based on interview and record review, the facility failed to follow the care plan for two (Resident #1 and #2) of four residents sampled for pain management associated with end of life care. The facility's failure to provide resident #1 and #2 pain medication resulted in actual harm, as the residents experienced significant episodic pain related to the disease process and the interventions the residents received. Reference F309. The findings include: 1) Review of the Admission Record of Resident #1 revealed that she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's Physician order [REDACTED]. Review of the Comprehensive Care Plan for Resident #1 revealed, "Resident at risk for pain r/t disease process: History of [MEDICAL CONDITION] with [MEDICAL CONDITION], stage 3 sacral ulcer. Goal: Resident will not have discomfort related to side effects of [MEDICATION NAME] through the next review; Resident will not have an interruption in normal activities due to pain through the review date. Interventions: Administer [MEDICATION NAME] as per orders. Give ? hour before treatments or care, position resident for comfort, identify area of discomfort. Assess for pain and relief post interventions, anticipate the resident's need for pain relief and respond immediately to any complaint of pain." During interview on 12/24/14 at 10:57am with the Wound Care nurse, it was reported, "Resident (#1) is not routinely medicated before wound care, but the resident has never complained of pain during the wound care procedure. The resident receives pre-medication for pain, if the resident complains of pain during the treatment, and he will stop the treatment and get an order for [REDACTED]. 2) Review of the Admission Record of Resident #2 revealed, she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's Physician order [REDACTED]. Review of the Care Plan for Resident #2 revealed, "Resident has potential for pain and discomfort related to her disease process; History of fall with fracture. Goal: The resident will verbalize adequate relief of pain through the review date. Interventions: Notify Medical Director/Advanced Registered Nurse Practitioner (MD/ARNP) if no pain relief, Monitor for pain every shift, maintain comfort measures; evaluate the effectiveness of pain interventions, impact on functional ability and impact on cognition." Interview with the Licensed Practical Nurse (LPN-A) on 12/24/14 at 10:27am revealed, the resident was on the unit for one day, was confused and would yell out, but would not remember yelling when staff went to the room. She complained of pain and was initially treated with Tylenol. The residents roommate complained, about the resident yelling all night, this information was given to her by the night staff, but she was not sure whether the resident was assessed for pain. LPN-A reported, the residents family requested that the resident receive [MEDICATION NAME], because the Tylenol was not effective.