Every finding on record at Mountain View Nursing Home

Based on observations and staff interview, facility staff failed to maintain one of 40 resident rooms in homelike condition, resident room [ROOM NUMBER]. The findings include:Facility staff failed to repair a section of wall next to the resident's bed in room [ROOM NUMBER]. On 10/08/2025 at approximately 12:24 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. On 10/08/2025 at approximately 2:40 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. On 10/08/2025 at approximately 4:20 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. On 10/09/2025 at approximately 7:15 a.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. The facility's receipt from (Name of Store) dated 09/17/2025 documented in part 20 square feet of floor planking. On 10/09/2025 approximately 1:10 p.m. an interview was conducted with OSM (other staff member) #1, maintenance supervisor. When asked to describe the procedure for making repairs he stated the staff will either verbally notify him of something in need of repair, receive an email from staff or receive a phone call/text message. He further stated that there is a Maintenance Request Sheet at the nurse's station for staff to complete for needed repairs. When asked how often he checks the Maintenance Request Sheet he stated that it is checked sporadically. OSM #1 also stated he conducts rounds in the facility three to four times a week and does spots in some resident rooms. At approximately 1:20 p.m. an observation of resident room [ROOM NUMBER] was conducted with OSM #1. After observing the wall next to the resident's bed, he stated that there was a plan in place to fix the wall however, he did not have anything in writing describing the plan or timeframe for repairing the wall. He stated that the idea was to use floor planking and chair rail on the wall to give the appearance of wainscoting (wooden paneling that lines the lower part of the walls of a room). OSM #1 was asked to measure the area of the wall that was damaged. On 10/09/2025 at approximately 1:30 p.m. OSM #1 provided the surveyor with a copy of a receipt from (Name of Store) dated 09/17/2025. He stated that the receipt was for the supplies purchased for the repair in room [ROOM NUMBER]. He further stated the damaged area of the wall was approximately 16 inches high by 20 inches long. After reviewing the receipt for supplies from (Name of Store) dated 09/17/2025 he stated that the reasonable amount of time to make the repair would have been two weeks from the time the supplies were purchased. When asked if room [ROOM NUMBER] presented a homelike appearance he stated no. On 10/09/2025 at approximately 3:40 p.m. ASM (administrative staff member) #1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide complete respiratory services for one of 19 residents in the survey sample, Resident #33.The findings include: For Resident #33 (R33), the facility staff failed to clarify oxygen rate of administration for as needed orders.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/22/2025, the resident was assessed as being cognitively intact. R33 was not assessed as using oxygen at the time of the assessment.On 10/8/2025 at 2:23 p.m., an interview was conducted with R33 in her room. R33 was observed sitting in a chair with an oxygen concentrator at the bedside containing a nasal cannula inside of a closed plastic bag. When asked about oxygen, R33 stated that she wore the oxygen at night sometimes when she felt that she needed it.Review of the physician orders documented in part,Oxygen via nasal cannula or mask at bedtime for comfort. Order Date: 09/01/2025.Oxygen via nasal cannula or mask as needed for SOB (shortness of breath)/Comfort. Order Date: 09/01/2025. The physician orders failed to evidence a rate for the oxygen.Review of the progress notes documented in part, 08/27/2025 15:55 (3:55 p.m.) Note Text: Standing order for oxygen via nasal cannula initiated. Per daughter's request for comfort at night. Continue plan of care as directed.The comprehensive care plan for R33 documented in part, [Name of R33] has Shortness of Breath at times r/t (related to) aging and her disease process. Date Initiated: 05/15/2024. Under Interventions/Tasks it documented in part, .Oxygen therapy per facility protocol. Date Initiated: 11/26/2024 .Review of the eTAR (electronic treatment administration record) for R33 dated 9/1-9/30/25 and 10/1-10/31/25 documented the oxygen order at bedtime for comfort. It documented use of the oxygen at bedtime 26 of 36 days reviewed with a flow rate of 1 lpm (liter per minute) documented on 9/6/25 and 9/13/25. The eTARs failed to evidence the flow rate administered for the other dates reviewed.On 10/9/2025 at 3:07 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that R33 used the oxygen for comfort. She stated that when staff utilized oxygen for comfort they used pulse oximetry monitoring and set the flow rate to the residents comfort. She stated that oxygen was administered by the nurses, and it required a physicians order. ASM #2 stated that the order for R33's oxygen should have some type of parameters for the nursing staff to follow for administration. Review of the [Name of facility] Standing Orders dated 5/21/2025 documented in part, .Procedures: Oxygen via nasal cannula or mask prn (as needed) for comfort/SOB, at rates per facility protocol .The facility Policy and Procedure for Oxygen Administration dated 5/12/2023 documented in part, Procedure: Physician orders: The nurse must ensure that a current order for oxygen therapy is in the resident's chart. Initiate a standing order per protocol if there is not one in place. (Refer to standing order sheet.) . These two devices will be the most often used in our facility. Nasal Cannula: Used to deliver 1-6 liters per minute . Simple mask: Used to deliver 5-15 liters per minute .On 10/9/2025 at approximately 3:42 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. No further information was provided prior to exit.

Based on staff interview, and clinical record review, the facility staff failed to obtain a physician ordered laboratory test for one of 19 residents in the survey sample, Resident #3.The findings include: For Resident #3 (R3), the facility staff failed to obtain a magnesium level ordered by the physician on 5/21/25. A review of R3's clinical record revealed a physician's order dated 5/21/25 for a magnesium level and other laboratory (lab) tests every six months in March and September. Further review of R3's clinical record revealed the other laboratory tests were obtained on 9/19/25 but the magnesium level was not obtained. On 10/9/25 at 3:01 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated physician orders for labs are entered into the computer system, listed in a book, and documented on a lab sheet. ASM #2 stated the other ordered labs for R3 were obtained in September 2025, but the magnesium level was missed. On 10/9/25 at 3:42 p.m. ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility did not have a policy regarding laboratory tests. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for medication administration, for two of 14 residents in the survey sample, Resident #7 and Resident #8. The findings include: 1. For Resident #7 (R7), the facility staff failed to clarify the dosing of an as needed order for the pain medication, Morphine Sulfate (1) oral solution. On the most recent MDS (minimum data set), an admission assessment with an ARD (Assessment Reference Date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section J documented R7 receiving scheduled pain medications during the assessment period. The physician orders for R7 documented in part, Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (milligram per milliliter) (Morphine Sulfate) Give 1 dose orally every 4 hours as needed for moderate to severe pain rated 5-10 or if not taking po (by mouth) meds. Give 0.25ml or 0.50ml. Order Date: 07/04/2023. Start Date: 07/04/2023. Review of the eMAR (electronic medication administration record) dated 7/1/2023-7/31/2023 for R7 documented in part, Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 dose orally every 4 hours as needed for pain Give 0.25ml or 0.50ml. -D/C (discontinue) Date- 07/04/2023 1021 (10:21 a.m.). It was documented on the eMAR that R7 received one dose at 12:59 p.m. on 7/3/2023 for a pain level of 7. Review of the eMAR (electronic medication administration record) dated 7/1/2023-7/31/2023 for R7 revealed in part, Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 dose orally every 4 hours as needed for moderate to severe pain rated 5-10 or if not taking po meds Give 0.25ml or 0.50ml. It was documented on the eMAR that R7 received doses on 7/6/2023 at 7:08 p.m. for a pain level of 6, 7/7/2023 at 11:35 a.m. for a pain level of 8, at 8:00 p.m. for a pain level of 7, on 7/9/2023 at 5:07 a.m. for a pain level of 8, at 3:43 p.m. for a pain level of 7, on 7/10/2023 at 9:02 a.m. for a pain level of 8, on 7/11/2023 at 11:10 a.m. for a pain level of 8, on 7/13/2023 at 1:10 p.m. for a pain level of 8, on 7/17/2023 at 12:36 p.m. for a pain level of 8, on 7/22/2023 at 1:27 p.m. for a pain level of 6, on 7/23/2023 at 6:14 p.m. for a pain level of 8, on 7/24/2023 at 6:16 p.m. for a pain level of 8, and on 7/25/2023 at 6:32 a.m. for a pain level of 7. The comprehensive care plan for R7 documented in part, (Name of R7) is receiving a regularly scheduled pain medication for pain r/t (related to) previous back injury and multiple past surgeries. Date Initiated: 04/25/2023. Created on: 04/25/2023. Revision on: 04/25/2023. On 8/2/2023 at 11:19 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that as needed pain medications were administered according to the order and they normally had numerical parameters to administer them. She stated that normally the medications stated to give for pain between 1-6 or 6-10 and the nurse would use the pain assessment to determine which medication to give. RN #1 reviewed the physicians order for the as needed morphine sulfate for R7 and stated that they were not sure why it was written that way and they felt that the nurses would start with the lowest dosage first and then give the higher dosage as needed. She stated that the order left the dosing at the nurses discretion and that was not in the nursing scope of practice and the order should be clarified with the physician. The facility policy Medication Liberalization Policy dated 5/4/2023 documented in part, .The nurse shall administer medication in such a way that would promote the homelike environment and not interfere with resident life and comfort, while remaining within safe, evidence-based nursing parameters . On 8/2/2023 at 12:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, medical doctor were made aware of the findings. No further information was presented prior to exit. References: (1) Morphine comes as a solution (liquid), an extended-release (long-acting) tablet, and as an extended-release (long-acting) capsule to take by mouth. The oral solution is usually taken every 4 hours as needed for pain. MS Contin brand and Arymo ER brand are extended-release tablets that are usually taken every 8 or every 12 hours. Morphabond brand extended-release tablets are usually taken every 12 hours. Kadian brand extended-release capsules are usually taken with or without food every 12 hours or every 24 hours. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682133.html 2. For Resident #8 (R8), the facility staff failed to follow professional standards of medication administration to assess the heart rate prior to administration of Digoxin (1). The physician orders for R8 documented in part, Digoxin Oral Tablet 125 MCG (microgram) (Digoxin) Give 1 tablet by mouth every day shift related to Left Ventricular Failure, Unspecified. Order Date: 04/04/2023. Start Date: 04/13/2023. Review of the eMAR (electronic medication administration record) dated 6/1/2023-6/30/2023 for R8 documented Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth every day shift related to Left Ventricular Failure, Unspecified. The eMAR revealed documentation that the Digoxin was administered to R8 each day but failed to evidence a heart rate assessment prior to administration. Review of the eMAR dated 7/1/2023-7/31/2023 for R8 revealed documentation that the Digoxin was administered to R8 each day but failed to evidence a heart rate assessment prior to administration. Review of the eMAR dated 8/1/2023-8/31/2023 for R8 revealed documentation that the Digoxin was administered to R8 on 8/1/2023 and 8/2/2023 but failed to evidence a heart rate assessment prior to administration. Review of the clinical record for R8 under Pulse Summary failed to evidence a pulse check on 6/1/2023, 6/2/2023, 6/4/2023-6/9/2023, 6/11/2023-6/16/2023, 6/18/2023-6/23/2023, 6/25/2023-6/30/2023, 7/2/2023-7/7/2023, 7/9/2023-7/13/2023, 7/17/2023-7/20/2023, 7/24/2023-7/28/2023 and 7/30/2023-8/2/2023. The comprehensive care plan for R8 documented in part, (Name of R8) is receiving regularly scheduled Digoxin Therapy r/t (related to) Left Ventricular Failure. Date Initiated: 04/12/2023. Created on: 04/12/2023. Revision on: 04/12/2023. On 8/2/2023 at 11:19 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they were not aware of any specific assessments prior to administering Digoxin to a resident. When asked about assessing the heart rate prior to administering Digoxin to a resident, RN #1 stated that they monitored residents heart rates at least daily and it was documented in the computer under the vital signs. She stated that she did not think that the nurses always checked the heart rate prior to administration but checked it sometime during the day and would notify the physician and assess further if it were lower than 60. On 8/2/2023 at 11:41 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that they had asked the physician about the Digoxin administration and had added heart rate monitoring to the eMAR for the Digoxin because the physician said that it would not hurt anything to have it there but was not necessary. ASM #2 stated that they had a nursing drug reference book that the staff used for medication administration and would provide the book for review and they were not sure if assessing the heart rate prior to administration of Digoxin was a nursing standard of practice. On 8/2/2023 at 11:50 a.m., an interview was conducted with ASM #3, medical doctor. ASM #3 stated that they were not aware that it was a expectation for nursing to assess the heart rate prior to administration of Digoxin and they felt that R8's pulse had not been an issue when they had reviewed the vital signs. On 8/2/2023 at 12:37 p.m., ASM #2, the director of nursing provided Nursing 2023 Drug Handbook by Wolters Kluwer and stated it was the drug reference book used by nursing staff. ASM #2 stated that they had spoken with ASM #3, the medical doctor and they felt that the heart rate assessment was not necessary. At this time, a request was made for a professional standard of practice stating that the heart rate monitoring was at the physician's discretion. Review of Nursing 2023 Drug Handbook by Wolters Kluwer provided by the facility documented on pages 433-437 in part, Digoxin .Administration PO (by mouth) .Before giving drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes (sudden increase or decrease in pulse rate, pulse deficit, irregular beats and, particularly, regularization of a previously irregular rhythm. If these occur, check BP (blood pressure) and obtain a 12-lead ECG (electrocardiogram) .Alert: Excessively slow pulse rate (60 beats/minute [bpm] or less) may be a sign of digitalis toxicity. Withhold the drug and notify prescriber . On 8/2/2023 at 12:43 p.m., ASM #3, medical doctor, stated that they were unable to provide a reference regarding nursing not having to check a pulse before administering Digoxin. On 8/2/2023 at 12:45 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, medical doctor were made aware of the findings. No further information was presented prior to exit. Reference: (1) Digoxin is used to treat heart failure and abnormal heart rhythms (arrhythmias). It helps the heart work better and it helps control your heart rate. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682301.html

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to monitor the function of Wander Guards used for the prevention of elopements, for two of 14 residents in the survey sample, Resident #7 and Resident #8. The findings include: 1. For Resident #7 (R7), the facility staff failed to monitor the functioning of the WanderGuard device (1) used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section E documented R7 displaying behaviors of rejection of care during the survey dates and not wandering during the assessment period. The physician orders for R7 documented in part, Wander Guard Bracelet for Safety every day shift for Safety, prevention of elopement. Order Date: 04/18/2023. Start Date: 04/25/2023. Review of the eTAR's (electronic treatment administration records) for R7 from 6/1/2023 through 8/1/2023 documented the Wander Guard Bracelet in place each day, however there was no documentation that it was checked to ensure it was functioning. The progress notes for R7 documented in part, - 4/25/2023 13:23 (1:23 p.m.) .Son/RR (resident representative) completed admission paperwork with DON (director of nursing). RR requesting to pick up copy of written plan care at later date when he returns to facility to visit his mother. RR states resident has been known to try leaving home and locks his doors so Resident cannot elope, RR thinks wanderguard bracelet is necessary for safety, Bracelet placed on resident's left wrist. - 5/12/2023 09:58 (9:58 a.m.) .Resident was brought out to be with staff, consumed small snack and sat in recliner for short period of time, then wandered halls with staff direct supervision safety. Resident stated that she was going home and how do I get out of here? Explained that she was going to stay here for now and provided the hour of the night. Resident just continued to wander with staff at her side . - 6/10/2023 22:59 (10:59 p.m.) Note Text :Resident ROM (range of motion) per usual this shift. Resident wandered facility per usual and had interactions with staff often during this shift. A Wandering Risk Evaluation for R7 dated 4/25/2023 documented the resident having a history of wandering and being a high risk for wandering. The comprehensive care plan for R7 documented in part, (Name of R7) is a potential elopement risk/wanderer AEB (as evidenced by) Disoriented to place d/t (due to) recent admission r/t (related to) aging and her disease process. Date Initiated: 04/25/2023. Created on: 04/25/2023. Revision on: 04/25/2023. On 8/2/2023 at 11:19 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the WanderGuards were checked for placement every day on the day shift. She stated that the staff did not check the device for function but if they felt that the device was not working properly they contacted maintenance to check the doors and fix it. She stated that they would know that the device was not working properly if the resident went to the doors and the alarms did not go off or lock. On 8/2/2023 at 11:41 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that WanderGuards were checked by staff daily for placement only and the staff did not check them for function. She stated that if an issue was suspected they contacted maintenance who came to check the doors to make sure they were working properly. She stated that they were not aware of any elopements at the facility. On 8/2/2023 at 11:53 a.m., an interview was conducted with OSM (other staff member) #3, maintenance supervisor. OSM #3 stated that when a resident required a WanderGuard they supplied them to the staff. OSM #3 stated that he went around the facility monthly and checked the door locks to make sure they functioned as intended. He stated that he had a hand held device that checked the magnetic field for door function but did not check the wander guard devices for function. He stated that the specific wander guards would not be checked unless there was a question whether they were working or not. On 8/2/2023 at 12:40 p.m., ASM #1, the administrator stated that the facility had a routine TAR (treatment administration record) check for WanderGuard placement but not a specific policy for Wander Guard function. On 8/2/2023 at 12:45 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, medical doctor were made aware of the concern. No further information was provided prior to exit. Reference: (1) A WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers. Even more important, when paired with optional magnetic door locks, the door automatically locks. When a caregiver needs to escort a wander-prone resident outside the safe area, the caregiver can use a secure code to bypass the system. The system also works in areas without physical doors. These virtual boundaries help a community feel welcoming without compromising safety. This information was obtained from the website: https://www.securitashealthcare.com/blog/3-reasons-you-need-wanderguard-system 2. For Resident #8 (R8), the facility staff failed to monitor the functioning of the WanderGuard device used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/18/2023, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented R8 not displaying any wandering behaviors during the assessment period. The physician orders for R8 documented in part, Check Wanderguard bracelet for placement. every day shift for Wandering. Order Date: 04/12/2023. Start Date: 04/13/2023. Review of the eTAR's (electronic treatment administration records) for R8 from 6/1/2023 through 8/1/2023 documented the Wander Guard Bracelet in place each day, however there was no documentation that it was checked to ensure it was functioning. The progress notes for R8 documented in part, - 4/14/2023 06:09 (6:09 a.m.) Note Text : New admit note. Resident did not sleep most of the night and wanted to wander. She was redirectable and pleasant . - 4/18/2023 23:17 (11:17 p.m.) Note Text : Day 7/7 new admit. Resident confused and exit seeking this shift. Stated someone was coming for her and she did not want to miss her ride. A Wandering Risk Evaluation for R8 dated 4/12/2023 documented the resident having a history of wandering and being a high risk for wandering. The comprehensive care plan for R8 documented in part, (Name of R8) is an elopement risk/wanderer AEB (as evidenced by) Impaired safety awareness r/t (related to) her disease process. Date Initiated: 04/13/2023. Created on: 04/13/2023. Revision on: 04/13/2023. On 8/2/2023 at 11:19 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the WanderGuards were checked for placement every day on the day shift. She stated that the staff did not check the device for function but if they felt that the device was not working properly they contacted maintenance to check the doors and fix it. She stated that they would know that the device was not working properly if the resident went to the doors and the alarms did not go off or lock. On 8/2/2023 at 11:41 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that WanderGuards were checked by staff daily for placement only and the staff did not check them for function. She stated that if an issue was suspected they contacted maintenance who came to check the doors to make sure they were working properly. She stated that they were not aware of any elopements at the facility. On 8/2/2023 at 11:53 a.m., an interview was conducted with OSM (other staff member) #3, maintenance supervisor. OSM #3 stated that when a resident required a WanderGuard they supplied them to the staff. OSM #3 stated that he went around the facility monthly and checked the door locks to make sure they functioned as intended. He stated that he had a hand held device that checked the magnetic field for door function but did not check the wander guard devices for function. He stated that the specific wander guards would not be checked unless there was a question whether they were working or not. On 8/2/2023 at 12:45 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, medical doctor were made aware of the concern. No further information was provided prior to exit.

Based on clinical record review, staff interview, and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for one of 14 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to implement the comprehensive care plan to check functioning of a WanderGuard device (1) used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section E documented R7 displaying behaviors of rejection of care during the survey dates and not wandering during the assessment period. The comprehensive care plan for R7 documented in part, (Name of R7) is a potential elopement risk/wanderer AEB (as evidenced by) Disoriented to place d/t (due to) recent admission r/t (related to) aging and her disease process. Date Initiated: 04/25/2023. Created on: 04/25/2023. Revision on: 04/25/2023. Under Interventions/Tasks it documented in part, .WANDER ALERT: Check device as required to make sure it is working properly. Date Initiated: 04/25/2023. Created on: 04/25/2023. Revision on: 04/25/2023. The physician orders for R7 documented in part, Wander Guard Bracelet for Safety every day shift for Safety, prevention of elopement. Order Date: 04/18/2023. Start Date: 04/25/2023. Review of the eTAR's (electronic treatment administration records) from 6/1/2023 through 8/1/2023 documented the Wander Guard Bracelet checked for placement each day, however there was no documentation that it was checked to ensure it was functioning. On 8/2/2023 at 11:19 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the WanderGuards were checked for placement every day on the day shift. She stated that the staff did not check the device for function but if they felt that the device was not working properly they contacted maintenance to check the doors and fix it. She stated that they would know that the device was not working properly if the resident went to the doors and the alarms did not go off or lock. She stated that the purpose of the care plan was to know how to care for the resident and the staff implemented the care plan by going over it monthly in the meetings, reading the notes daily and reviewing the care plan. She stated that the care plan should be implemented so that the resident received good care that met his or her preferences. On 8/2/2023 at 11:41 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that WanderGuards were checked by staff daily for placement only and the staff did not check them for function. She stated that if an issue was suspected they contacted maintenance who came to check the doors to make sure they were working properly. She stated that they were not aware of any elopements at the facility. On 8/2/2023 at 11:53 a.m., an interview was conducted with OSM (other staff member) #3, maintenance supervisor. OSM #3 stated that when a resident required a WanderGuard they supplied them to the staff. OSM #3 stated that he went around the facility monthly and checked the door locks to make sure they functioned as intended. He stated that he had a hand held device that checked the magnetic field for door function but did not check the wander guard devices for function. He stated that the specific wander guards would not be checked unless there was a question whether they were working or not. The facility policy, Procedure for Updating Care Plans dated 5/17/2023 failed to evidence guidance on implementation of the care plan. On 8/2/2023 at 12:45 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, medical doctor were made aware of the concern. No further information was provided prior to exit. Reference: (1) A WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers. Even more important, when paired with optional magnetic door locks, the door automatically locks. When a caregiver needs to escort a wander-prone resident outside the safe area, the caregiver can use a secure code to bypass the system. The system also works in areas without physical doors. These virtual boundaries help a community feel welcoming without compromising safety. This information was obtained from the website: https://www.securitashealthcare.com/blog/3-reasons-you-need-wanderguard-system

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to adequately monitor a resident prior to administering a medication, for one of 14 residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to assess the heart rate prior to administration of Digoxin (1). The physician orders for R8 documented in part, Digoxin Oral Tablet 125 MCG (microgram) (Digoxin) Give 1 tablet by mouth every day shift related to Left Ventricular Failure, Unspecified. Order Date: 04/04/2023. Start Date: 04/13/2023. Review of the eMAR (electronic medication administration record) dated 6/1/2023-6/30/2023 for R8 documented Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth every day shift related to Left Ventricular Failure, Unspecified. The eMAR revealed documentation that the Digoxin was administered to R8 each day but failed to evidence a heart rate assessment prior to administration. Review of the eMAR dated 7/1/2023-7/31/2023 for R8 revealed documentation that the Digoxin was administered to R8 each day but failed to evidence a heart rate assessment prior to administration. Review of the eMAR dated 8/1/2023-8/31/2023 for R8 revealed documentation that the Digoxin was administered to R8 on 8/1/2023 and 8/2/2023 but failed to evidence a heart rate assessment prior to administration. Review of the clinical record for R8 under Pulse Summary failed to evidence a pulse check on 6/1/2023, 6/2/2023, 6/4/2023-6/9/2023, 6/11/2023-6/16/2023, 6/18/2023-6/23/2023, 6/25/2023-6/30/2023, 7/2/2023-7/7/2023, 7/9/2023-7/13/2023, 7/17/2023-7/20/2023, 7/24/2023-7/28/2023 and 7/30/2023-8/2/2023. The comprehensive care plan for R8 documented in part, (Name of R8) is receiving regularly scheduled Digoxin Therapy r/t (related to) Left Ventricular Failure. Date Initiated: 04/12/2023. Created on: 04/12/2023. Revision on: 04/12/2023. On 8/2/2023 at 11:19 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they were not aware of any specific assessments prior to administering Digoxin to a resident. When asked about assessing the heart rate prior to administering Digoxin to a resident, RN #1 stated that they monitored residents heart rates at least daily and it was documented in the computer under the vital signs. She stated that she did not think that the nurses always checked the heart rate prior to administration but checked it sometime during the day and would notify the physician and assess further if it were lower than 60. On 8/2/2023 at 11:41 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that they had asked the physician about the Digoxin administration and had added heart rate monitoring to the eMAR for the Digoxin because the physician said that it would not hurt anything to have it there but was not necessary. ASM #2 stated that they had a nursing drug reference book that the staff used for medication administration and would provide the book for review and they were not sure if assessing the heart rate prior to administration of Digoxin was a nursing standard of practice. On 8/2/2023 at 11:50 a.m., an interview was conducted with ASM #3, medical doctor. ASM #3 stated that they were not aware that it was a expectation for nursing to assess the heart rate prior to administration of Digoxin and they felt that R8's pulse had not been an issue when they had reviewed the vital signs. On 8/2/2023 at 12:37 p.m., ASM #2, the director of nursing provided Nursing 2023 Drug Handbook by Wolters Kluwer and stated it was the drug reference book used by nursing staff. ASM #2 stated that they had spoken with ASM #3, the medical doctor and they felt that the heart rate assessment was not necessary. At this time, a request was made for a professional standard of practice stating that the heart rate monitoring was at the physician's discretion. Review of Nursing 2023 Drug Handbook by Wolters Kluwer provided by the facility documented on pages 433-437 in part, Digoxin .Administration PO (by mouth) .Before giving drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes (sudden increase or decrease in pulse rate, pulse deficit, irregular beats and, particularly, regularization of a previously irregular rhythm. If these occur, check BP (blood pressure) and obtain a 12-lead ECG (electrocardiogram) .Alert: Excessively slow pulse rate (60 beats/minute [bpm] or less) may be a sign of digitalis toxicity. Withhold the drug and notify prescriber . On 8/2/2023 at 12:43 p.m., ASM #3, medical doctor, stated that they were unable to provide a reference regarding nursing not having to check a pulse before administering Digoxin. On 8/2/2023 at 12:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, medical doctor were made aware of the findings. No further information was presented prior to exit. Reference: (1) Digoxin is used to treat heart failure and abnormal heart rhythms (arrhythmias). It helps the heart work better and it helps control your heart rate. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682301.html

Based on staff interview and facility document review, the facility staff failed to ensure the required QAPI (quality assurance and performance improvement) committee members attended the QAPI meeting for one of four quarterly meetings in 2022. The findings include: The facility staff failed to ensure the Director of Nursing attended the second quarter QAPI meeting on 7/25/22. A review of the 7/25/22 QAPI meeting sign-in sheet failed to reveal the signature of the Director of Nursing. On 8/2/23 at 8:31 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 stated QAPI meetings are held quarterly, and the Director of Nursing is supposed to attend. ASM #1 stated the former Director of Nursing did not attend the 7/25/22 QAPI meeting because he was on vacation. On 8/2/23 at 12:49 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Quality Assurance and Performance Improvement documented, 2. The QA (quality assurance) Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The director of nursing services . b. Meet at least quarterly .

Based on observation, staff interview and facility document review, the facility staff failed to post complete nurse staffing information for two of two days reviewed. The findings include: The facility staff failed to post the total number of RNs (registered nurses), LPNs (licensed practical nurses) and CNAs (certified nursing assistants) directly responsible for resident care per shift on 8/1/23 and 8/2/23. A review of the nurse staffing information postings for 8/1/23 and 8/2/23 failed to reveal documentation of the total number of RNs, LPNs and CNAs directly responsible for resident care per shift (the postings only documented hours worked). On 8/2/23 at 10:14 a.m., an interview was conducted with OSM (other staff member) #1 (administrative assistant). OSM #1 stated the nurse staffing information postings document the census and the amount of RN, LPN and CNA hours worked for each shift. OSM #1 stated she was not aware that the total number of RNs, LPNs and CNAs for each shift should be documented on the postings. On 8/2/23 at 12:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Nurse Staffing Posting Information documented, 1. The Daily Staffing Sheet will be posted and contain the following information: a. Facility name b. Current date c. Current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides/Nurse Aide .

Based on observation and staff interview, it was determined the facility staff failed to store food in a safe and sanitary manner. The facility staff failed to dispose of expired food during an observation on [DATE] at 11:09 AM. The findings include: On [DATE] at 11:09 AM, an observation was conducted in the main kitchen. In the dry storage room, a 4.64 pound bag of dried milk was labeled opened [DATE], use by [DATE]. A 49.6 ounce cornbread stuffing mix bag was labeled opened [DATE], use by [DATE]. OSM (other staff member) #1, a dietary aide, was shown the two bags. When asked what the dates signified, OSM #1 stated, That means that they should be disposed of by those 'use by' dates. I will dispose of them now. OSM #3, the dietary manager, was informed of the expired items on [DATE] at 11:45 AM. A policy on food storage/expired food was requested on [DATE] at 3:20 PM. On [DATE] at 4:30 PM ASM (administrative staff member) #1, the administrator, was made aware of the above finding and stated, We do not have any policy regarding food storage or expired food. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise a comprehensive care plan for 2 of 19 residents in the survey sample; Residents #5 and #34. The findings include: 1. For Resident #5, the facility staff failed to review and revise the comprehensive care plan for the use of an opioid medication regarding the monitoring of related side effects and adverse reactions. Resident #5 was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/9/22. The resident was coded as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing; supervision for dressing and transfers, and was independent for all other areas of activities of daily living. A review of the physician's orders revealed an order dated 5/28/21 for, [MEDICATION(S)] (1) Tablet 50 MG (milligrams) Give 1 tablet by mouth two times a day for pain. A review of the comprehensive care plan revealed one dated 5/18/20 for, (Resident #5) has chronic pain r/t (related to) aging and disease process. This care plan included an intervention dated 5/27/20 for, Give medications as ordered. Monitor for effectiveness. However, the care plan did not include any intervention for monitoring of side effects and adverse reactions related to pain medication. On 1/27/22 at 8:53 AM in an interview with LPN #1 (Licensed Practical Nurse) the MDS nurse, she stated that the Pain care plan addresses administering medications as ordered but that she did not know it had to be as specific as to address side effects or adverse reactions of pain medication. A review of the facility policy, Policy for Updating Careplans, revealed the policy only addressed updating the care plan for the specific areas of skin impairment, antibiotic and fall. It was not written as a guide for the comprehensive care plan as a whole, for any required updates and revisions relating to any resident specific changes and needs. On 1/27/22 at 9:38 AM, ASM #1 (Administrative Staff Member), the Administrator, stated that he did not have a policy for anything more general for updating care plans that applied to any/all resident needs outside of skin impairment, antibiotic, and falls. When asked what professional standards the facility uses, he stated that he believed it was Lippincott. According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77: A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . No further information was provided by the end of the survey. References: (1) [MEDICATION(S)] is used to treat moderate to moderately severe pain and is in a class of medications called opiate (narcotic) analgesics. Information obtained from https://medlineplus.gov/druginfo/meds/a 1.html 2. For Resident #34, the facility staff failed to review and revise the comprehensive care plan for the use of an opioid medication regarding the monitoring of related side effects and adverse reactions. Resident #34 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/2/21. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing, extensive care for all other areas of activities of daily living except for eating, which was coded as requiring supervision only. A review of the physician's orders revealed one dated 6/18/21 for, [MEDICATION(S)] (1) Tablet 50 MG (milligrams) Give 1 tablet by mouth every day and evening shift for pain. A review of the comprehensive care plan revealed one dated 5/28/21 revealed, (Resident #34) has pain r/t (related to) the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This care plan included an intervention dated 5/28/21 for, Give medications as ordered. Monitor for effectiveness. However, the care plan did not include any intervention for monitoring of side effects and adverse reactions related to pain medication. On 1/27/22 at 8:53 AM in an interview with LPN #1 (Licensed Practical Nurse) the MDS nurse, she stated that the Pain care plan addresses administering medications as ordered but that she did not know it had to be as specific as to address side effects or adverse reactions of pain medication. A review of the facility policy, Policy for Updating Careplans, revealed the policy only addressed updating the care plan for the specific areas of skin impairment, antibiotic and fall. It was not written as a guide for the comprehensive care plan as a whole, for any required updates and revisions relating to any resident specific changes and needs. On 1/27/22 at 9:38 AM, ASM #1 (Administrative Staff Member) the Administrator, stated that he did not have a policy for anything more general for updating care plans that applied to any/all resident needs outside of skin impairment, antibiotic, and falls. When asked what professional standards the facility uses, he stated that he believed it was Lippincott. According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77: A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . No further information was provided by the end of the survey. References: (1) [MEDICATION(S)] is used to treat moderate to moderately severe pain and is in a class of medications called opiate (narcotic) analgesics. Information obtained from https://medlineplus.gov/druginfo/meds/a 1.html

Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to follow physician's orders for 1 of 19 residents in the survey sample, Resident #20. The facility staff failed to obtain a monthly weight in September 2021 for Resident #20. The findings include: Resident #20 was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/10/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record revealed a physician's order dated 3/1/20 for Obtain weight monthly and as needed. A review of the weights documented in the clinical record revealed that there was no weight recorded for September 2021. The August 2021 weight was recorded on 8/3/21 at 146.2 pounds and on 10/3/21 at 143.6 pounds. This reflected a weight loss of 2.6 pounds over the period of time that a weight was missed. A review of the comprehensive care plan revealed one dated 5/2/18 and revised on 1/20/20 for (Resident #20) has potential for having a nutritional problem r/t (related to) disease process diagnosis (sic) of Dementia, Diabetes, and Alzheimer's Disease. Interventions included one dated 5/2/18 for Weigh monthly and PRN (as needed). On 1/27/22 at 10:08 AM, in an interview with ASM #2 (Administrative Staff Member) the Director of Nursing, he stated that the facility realized in October (2021) that the September (2021) weight was missed and that there was nothing that could be done about it by then. It was missed. A copy of the facility policy on following physician's orders was requested. On 1/27/22 at 10:18 AM, ASM #2 provided the Weight Policy and Procedure stating that the facility does not have a policy on following physicians orders. He stated that it is the expectation that orders are followed. A review of the above weight policy revealed, B. Every client should be weighed at least once a month and recorded on the Monthly Weight/Vital Signs Record sheet C. All monthly weights should be obtained by the 10th of each month, if at all possible. On 1/27/22 at 10:08 AM, ASM #2 was made aware of the findings. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined that the facility QAPI (quality assurance and performance improvement) committee failed to meet in two of four quarters in 2021. The facility QAPI committee failed to meet in the third and fourth quarters of 2021. The findings include: A review of QAPI committee meeting sign in sheets revealed meetings for the first and second quarters of 2021. The review failed to include sign in sheets for the third and fourth quarters of 2021. On 1/27/22 at 9:38 a.m., ASM (administrative staff member) #1, the administrator, was interviewed. He stated the QAPI committee includes him, the directors of personnel and discipleship, the director of nursing, the assistant director of nursing, the MDS (minimum data set) coordinator, the CNA (certified nursing assistant) supervisor, activities director, social services director, housekeeping supervisor, maintenance supervisor, dietary manager, occupational health nurse, consultant pharmacist, and medical director. He stated ordinarily the QAPI committee meets four times a year, at least once a quarter. When asked why there was no evidence that the committee met in quarters three and four of 2021, he stated he just did not get it scheduled. He stated the meeting for combined third and fourth quarters of 2021 is scheduled for the upcoming week. He stated it was difficult to coordinate remote schedules with the consultant pharmacist and medical director. A review of the facility policy, Quality Assurance and Performance Improvement, revealed, in part: The QA (quality assurance) committee shall .meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined that the facility failed to post nursing staffing hours as required. The facility's staff posting for the past 30 days did not contain the required hour amounts of nursing staff. The findings include: On 1/25/21 at 1:08 p.m., the facility's staff posting was observed on the table near the nurse desk. The posting contained the facility census, vertical columns for the dates for all seven days in the week, the listing for registered and licensed practical nurses, and for nursing assistants. The posting contained horizontal rows containing the actual number of each of these staff members working on each shift. The posting did not contain the number of hours worked on each shift by each type of nursing staff member. On 1/25/21 at 4:55 p.m., ASM (administrative staff member) #1, the administrator, was asked to review the staff posting for all elements required by the regulation. On 1/26/21 at 11:26 a.m., ASM #1 stated he had identified several elements that the current staffing posting did not contain: accurate resident census, LPNs (licensed practical nurses) and RNs (registered nurses) were not distinguished from each other, and the posting did not contain the actual number of hours worked by each type of staff member. He stated the secretary has been taking care of filling out this form. On 1/26/21 at 11:29 a.m., OSM (other staff member) #5, the secretary, was interviewed. She stated she looks over the schedule for each week, and has been filling out the staffing according to the number of RNs, LPNs, and CNAs. She stated she was not aware until the afternoon before that she was supposed to include the number of actual hours worked by each type of staff member on the staff posting. On 1/26/21 at 11:40 a.m., ASM #1 stated the facility did not have a policy regarding the nursing staffing posting. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 16 residents in the survey sample, Resident #2. On 1/2/21, the facility staff failed to implement a clip alarm while Resident #2 was on the toilet, per the resident's comprehensive care plan, and Resident #2 sustained a fall with no injury. The findings include: Resident #2 was admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/30/21, coded the resident's cognition as moderately impaired. Section G coded Resident #2 as requiring extensive assistance of two or more staff with transfers. Section J coded Resident #2 as having sustained two or more falls with no injury since the prior assessment. Review of Resident #2's clinical record revealed a physician's orders [REDACTED]. Resident #2's comprehensive care plan revised on 5/5/20 documented, (Resident #2) has a risk for falls due to [DIAGNOSES REDACTED].Clip alarm while on toilet . Further review of Resident #2's clinical record revealed the resident sustained [REDACTED]. A fall risk evaluation dated 1/2/21 documented a score of 17. A nurse's note dated 1/2/21 documented, Resident was found at approximately 1430 (2:30 p.m.) laying on her back in her bathroom. When resident was asked what happened, she stated that she fell 'on her butt'. Denied hitting her head when asked by staff. ROM (Range of Motion) per her normal. No injuries noted. Care plan reviewed . Another nurse's note dated 1/2/21 documented, CNAs (certified nursing assistants) educated on careful use of clip alarm while on toilet as well as frequent monitoring as stated in care plan. A fall investigation form dated 1/3/21 documented, Did CNA have all safety devices properly in place? If no, explain please. No. CNA stated she did not have clip alarm on resident. She said it had not worked earlier . A CNA Incident/Accident Report Sheet with an incident date of 1/2/21 and signed by CNA #4 and RN (registered nurse) #1 documented, 7. How could the CNA have prevented the incident from occurring? Checked up on her sooner, have a working clip alarm . On 2/10/21 at 11:08 a.m., a telephone interview was conducted with CNA #4. CNA #4 stated a clip alarm was not on Resident #2 while she was on the toilet on 1/2/21 because the clip alarm was not working at the time. On 2/10/21 at 11:10 a.m., an interview was conducted with RN #1. RN #1 stated the purpose of care plans is to provide standard continuity of care and to ensure the same quality of care is delivered through each shift. RN #1 stated the facility staff checks residents' care plans for fall risk interventions and the care plan should absolutely be followed. RN #1 stated she assessed Resident #2 when she fell on [DATE]. RN #1 stated she did not remember if a clip alarm was present but the CNA reported the clip alarm was not on Resident #2 when she fell in the bathroom. The facility policy regarding the updating of care plans did not contain specific documentation regarding the implementation of care plans. On 2/10/21 at 11:42 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a fall risk intervention for 1 of 16 residents in the survey sample, Resident #2. On 1/2/21, the facility staff failed to implement a physician ordered clip alarm while Resident #2 was on the toilet and Resident #2 sustained a fall with no injury. The findings include: Resident #2 was admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/30/21, coded the resident's cognition as moderately impaired. Section G coded Resident #2 as requiring extensive assistance of two or more staff with transfers. Section J coded Resident #2 as having sustained two or more falls with no injury since the prior assessment. Review of Resident #2's clinical record revealed a physician's orders [REDACTED]. Resident #2's comprehensive care plan revised on 5/5/20 documented, (Resident #2) has a risk for falls due to [DIAGNOSES REDACTED].Clip alarm while on toilet . Further review of Resident #2's clinical record revealed the resident sustained [REDACTED]. A fall risk evaluation dated 1/2/21 documented a score of 17. A nurse's note dated 1/2/21 documented, Resident was found at approximately 1430 (2:30 p.m.) laying on her back in her bathroom. When resident was asked what happened, she stated that she fell 'on her butt'. Denied hitting her head when asked by staff. ROM (Range of Motion) per her normal. No injuries noted. Care plan reviewed . Another nurse's note dated 1/2/21 documented, CNAs (certified nursing assistants) educated on careful use of clip alarm while on toilet as well as frequent monitoring as stated in care plan. A fall investigation form dated 1/3/21 documented, Did CNA have all safety devices properly in place? If no, explain please. No. CNA stated she did not have clip alarm on resident. She said it had not worked earlier . A CNA Incident/Accident Report Sheet with an incident date of 1/2/21 and signed by CNA #4 and RN (registered nurse) #1 documented, 7. How could the CNA have prevented the incident from occurring? Checked up on her sooner, have a working clip alarm . On 2/10/21 at 11:08 a.m., a telephone interview was conducted with CNA #4. CNA #4 stated a clip alarm was not on Resident #2 while she was on the toilet on 1/2/21 because the clip alarm was not working at the time. On 2/10/21 at 11:10 a.m., an interview was conducted with RN #1. RN #1 stated she assessed Resident #2 when she fell on [DATE]. RN #1 stated she did not remember if a clip alarm was present but the CNA reported the clip alarm was not on Resident #2 when she fell in the bathroom. The facility policy regarding falls documented, Falls are a common source of injury and death among the elderly. It is the responsibility of all staff to assist in identifying risk factors and to carry out established plans to minimize falls . On 2/10/21 at 11:42 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to ensure dishes were cleaned in a sanitary manner. The facility staff failed to ensure the dishwasher got to 180 degrees Fahrenheit during the rinse cycle. The findings include: On 02/19/19 at approximately 11:58 a.m., an observation was made of dishwashing in the kitchen after the morning meal. Observation was made of the dishwasher while in use during the initial tour of the kitchen with OSM (other staff member) #3, the Dietary Manager. The maximum temperature observed during the rinse cycle was 151 degrees Fahrenheit. On 02/19/19 at approximately 12:01 p.m., a second observation was made of dishwashing in the kitchen after the morning meal with OSM #3. Observation of the dishwasher while use, revealed the maximum temperature during the rinse cycle was 153 degrees Fahrenheit. On 02/19/19 at approximately 12:03 p.m., an interview was conducted OSM# 3, the Dietary Manager. OSM #3 was asked how the facility dishwasher sanitized dishes. OSM #3 replied, The dishwasher uses hot temperatures to kill any germs. OSM #3 was asked what temperature is required to sanitize dishes. OSM #3 replied, It has two cycles the first (hot water wash) is supposed to get to 150 (degrees Fahrenheit) and the second is supposed to get to 180 (degrees Fahrenheit). When asked if the dishwasher had sanitized the dishes that were washed from the morning meal, OSM #2 replied, No. OSM #3 explained, It (the dishwasher) had been working but we have been having problems with it. On the 7th (02/07/19), the dishwasher started not getting up to temperature. I called maintenance and they came up and fixed it. OSM #3 was asked if the dishwasher should be used if not reaching the proper temperature to sanitize dishes, OSM #3 replied, No, the residents could get sick. OSM #3 was asked if the facility keeps a dishwasher temperature log, OSM #3 replied, Yes. OSM #3 then supplied this surveyor with the dishwashing logs from (MONTH) and February. On 02/19/19 at approximately 12:30 p.m., an observation was made of the dishwashing temperature log from (MONTH) and (MONTH) 2019. The temperature logs documented date, initials, wash (150), and rinse (180) temperatures for washes following the three meals each day of the month. For the month of (MONTH) 2019. No temperatures were recorded following the evening meals on (MONTH) 2nd, 3rd, 11th, 12th, 13th, 16th, 20th and 21st. For (MONTH) 23, no temperatures were recorded. For (MONTH) 9, 12, 15 and 19th, no temperatures were recorded. For (MONTH) 7, temperatures were not recorded for washes following first and second meals. For (MONTH) 8 and 9th temperatures following, the second and third meals were not recorded. No temperatures recorded were below 150 degrees Fahrenheit for the wash the hot water wash or below 180 degrees for the rinse cycle. On 02/19/19 at approximately 1:00 p.m., an interview was conducted with OSM #3, while reviewing the (MONTH) and (MONTH) 2019 dishwashing logs. OSM #3 was asked why the dishwasher log did not have temperatures recorded consistently. OSM #3, replied, Sometimes the dishwashers forget. OSM #3 was asked why the temperatures had not been recorded on the days when she knew the dishwasher was not properly functioning. OSM #3 replied, I don't know. On 02/19/19 at approximately 02:12 p.m., an interview was conducted with OSM #4, dietary manager aide. OSM #4 was asked if the dishwashing temperatures should be recorded on the temperature log after each meal. OSM #4 replied, Yes, we are supposed to record it three times after each meal. OSM #4 was asked why it's important to know the temperatures of the dishwasher. OSM #4 replied, So we know that the dishes have been thoroughly cleaned. On 02/19/19 at approximately 3:03 p.m., a third observation was made of dishwasher in the kitchen with OSM #2, the maintenance assistant. Observation of the dishwasher in the kitchen revealed the maximum temperature during the rinse cycle was 191 degrees Fahrenheit. On 02/20/19 at approximately 03:40 p.m., an interview was conducted with OSM #5, Maintenance Director. OSM #5 was asked how the dishwasher sanitizes dishes, OSM #5 replied, It's supposed to get to 150 degrees Fahrenheit for wash and 180 degrees Fahrenheit for rinse. OSM #5 was asked if he knew the dishwasher was not reaching the proper temperature to sanitize dishes. OSM #5 replied, I did not know that it was this time, no one had told me. I was told that on the 8th (02/08/19) by (name of OSM #3) and I came and realized the high limit switch had been tripped. I reset the switch and the dishwasher temperatures went to 156 (degrees Fahrenheit wash) and 191 (degrees Fahrenheit rinse). Then on the next Monday (2/11/19) I got a call and it was not holding temperature (temperature), I came and found out the temperature probe was dirty. I then cleaned it and it (the dishwater) held temperature, and after that, I did not hear anything so I assumed it was fixed. After you, guys came (surveyors) I was told, and came, cleaned the hot water sensor, and called the manufacturer. The manufacturer told me that cleaning the sensor should work temporarily fix the problem until they can come and change the sensor. On 02/20/19 at approximately 03:45 p.m., the facilities monthly infection logs dated (MONTH) 2019 and (MONTH) 2019 were reviewed. No residents were documented as having infectious diarrhea. Review of the facility policy titled, Dishwashing documented, Keeps all dishes washed and put in their proper places. Assumes responsibility for the care and cleanliness of equipment in the dishwashing area. On 02/20/19 at 5:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the Administrative Assistant, ASM #3, the Director of Nursing and RN #1, the Assistant Director of Nursing, were made aware of the above concerns. No further information was obtained prior to exit.

Based on observation, facility document review and staff interview, the facility staff failed to follow infection control practices while providing feeding assistance for four residents during a dining observation. 1. A staff member failed to perform hand hygiene while providing feeding assistance to Residents #26 and #29 during a dining observation. 2. The facility staff, CNA (certified nursing assistant) #2 failed to perform hand hygiene while providing feeding assistance to Residents # 19 and #33, during a dining observation. The findings include: 1. A staff member failed to perform hand hygiene while providing feeding assistance to Residents #26 and #29 during a dining observation. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #26 with severely impaired cognitive skills and as requiring the extensive assistance of one person for eating. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed Resident #29 with severely impaired cognitive skills and as requiring the extensive assistance of one person for eating. A dining observation was conducted on 2/19/19 from 11:40 a.m. through 12:10 p.m. in the main dining room. Resident #26 and #29 were observed at this time seated at the middle table near the window feeding themselves lunch. On 2/19/19 at 11:44 a.m., certified nurses' aide (CNA) #1 sat next to Resident #29 and started feeding her the meal. CNA #1 touched the resident's utensils, glass and napkin while assisting her to eat. Without performing hand hygiene, CNA #1 went to Resident #26 and assisted her with eating her lunch. CNA #1 handled the resident's utensils, cup and napkin while feeding this resident. CNA #1 proceeded to go back and forth between Resident #26 and #29 two additional times, assisting them with eating and drinking. On 2/19/19 at 11:50 a.m., CNA #1 went to the kitchen area. Without performing hand hygiene, CNA #1 retrieved an ice cream cup from the kitchen freezer. CNA #1 then washed her hands at the kitchen sink and handed the ice cream cup to another staff member. CNA #1 returned to feeding Resident #26 at the table. CNA #1 went back and forth between Resident #26 and #29, three additional times feeding the residents. CNA #1 performed no hand hygiene after touching either residents' utensils, cups, straws and/or napkins. On 2/19/19 at 1:08 p.m., CNA #1 was interviewed about hand hygiene when providing meal assistance for residents. CNA #1 stated staff members tried to perform hand hygiene between contact with residents and their personal items. CNA #1 stated hand sanitizer was available in the dining room and small bottles of sanitizer were also available if needed. CNA #1 stated Residents #26 and #29 ate some of their meal on their own but needed assistance to finish the meal. On 2/20/19 at 8:12 a.m., ASM (administrative staff member) #2, the director of nursing (DON) was interviewed about hand hygiene between resident contacts during dining. The DON stated staff members were instructed to wash their hands before start of the tray line. The DON stated he did not think staff members were instructed to perform hand hygiene when going from one resident to another. The DON stated once hands were clean, washing hands between residents would take away from the homelike atmosphere. The DON stated he had been at the facility only a few months and was not sure if they had instructions that specified washing hands between residents. The facility's policy titled Procedure for Using Alcohol-Based Hand Rub (undated) documented, .The alcohol-based hand rub may be used routinely for hand hygiene, unless hands are visibly soiled; then soap-and-water handwashing is required . This procedure documented times to use alcohol-based hand sanitizer included, .After contact with a resident's intact skin (as in taking a pulse or blood pressure, or after lifting) .After contact with inanimate objects (including medical equipment) . The facility's policy titled Procedure for Handwashing (undated) documented, When to Wash Hands (at a minimum) .Before and after each resident contact .After touching a resident or handling his or her belongings Whenever hands are obviously soiled .After contact with any body fluids .After handling any contaminated items (linens, soiled diapers, garbage, etc.). These findings were reviewed with ASM #1, the administrator and ASM #2, director of nursing during a meeting on 2/20/19 at 5:15 p.m. 2. The facility staff, CNA (certified nursing assistant) #2 failed to perform hand hygiene while providing feeding assistance to Residents # 19 and #33, during a dining observation. Observation was made of the day room on 2/19/19 at 11:48 a.m. Two residents, Resident #19 and Resident #33 were seated at a counter in the day room. There was a staff member, CNA (certified nursing assistant) # 2 sitting between the two residents. CNA #2 was observed assisting the two residents with their noon meal. CNA #2 was observed with his left arm placed around Resident #19 and was feeding her with his right hand. He would then switch positions and have his right arm around Resident #33 and was feeding Resident #33 with his left hand. Between feeding each resident, CNA #2 was observed trying to reposition the residents using both hands to sit both residents either closer to the table or assist Resident #19 into a sitting position. At no time during the observation between 11:48 a.m. and 11:57 a.m., was CNA #2 observed washing his hands or using hand sanitizer between touching the residents. He assisted both residents with spoon feeding and assisting them with using their cups to drink. An interview was conducted with CNA #2 on 2/20/19 at 9:48 a.m. When asked about precautions staff take, if they are feeding more than one resident, CNA #2 stated, I need to keep my hands from being contaminated, touching any parts that would go into their mouths. I alternate between residents, using their individual utensils. The observation above was shared with CNA #2. CNA #2 stated, I guess I should be washing my hands in between residents. Ideally, yes, I should do something, washing or hand sanitizer. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 11/21/19, coded the resident as having both short and long term memory problems and as severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for eating. The comprehensive care plan dated, 1/25/17, revised on 12/9/18, documented in part, Focus: The resident has a need for assistance with ADL's (activities of daily living) r/t (related to) [MEDICAL CONDITION], dementia. The Interventions/Tasks documented in part, EATING: The resident is able to hold cup, feed self, eat finger foods independently however, requires staff to set up all meal trays during all meals and staff to provided supervision and/or assistance while eating during all meals. Resident #33 was admitted to the facility 1/26/17 with diagnoses, that included but were not limited to: depression, anxiety disorder, and Down's syndrome (A genetic condition in which a person has 47 chromosomes instead of the usual 46. The extra chromosome causes problems with the way the body and brain develop. Dow[DIAGNOSES REDACTED] is one of the most common causes of birth defects (2)). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/17/18, coded the resident as having both short and long term memory problems and was coded as being severely impaired to make daily cognitive decisions. Resident #33 was coded as requiring extensive assistance of one staff member for eating. The comprehensive care plan dated 2/11/17 and revised on 3/25/18, documented in part, Focus: The resident has an ADL (activity of daily living) Self Care Performance deficit r/t (related to) disease process [DIAGNOSES REDACTED]. Provide staff assistance as needed. ASM (administrative staff member) #1, the administrator, ASM #2, the administrator in training, ASM #3, the director of nursing, and RN (registered nurse) #1, the assistant director of nursing were made aware of the above findings on 2/20/19 at 5:16 p.m. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and Chapman, page 26. (2) This information was obtained from the following website: https://medlineplus.gov/ency/article/ 7.htm.

Based on staff interview and clinical record review, the facility staff failed to ensure one of 16 residents was free from unnecessary medications. Residents #9 had a physician's orders [REDACTED]. This prescription was continued beyond the 14-day limit without a specified duration. The findings include: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #9 as cognitively intact. Resident #9's clinical record documented a current physician's orders [REDACTED]. Resident #9's medication administration records from 12/1/18 through 2/18/19 documented the resident was administered the prn [MEDICATION NAME] once on 12/3/18 for [MEDICAL CONDITION]. A pharmacy recommendation signed by the physician on 1/19/18 documented, D/C (discontinue) prn [MEDICATION NAME]. A note dated 1/23/18 signed by the director of nursing at the bottom of this recommendation stated, Resident refused to have medication discontinued. MD (physician) contacted and order received to continue per resident request. The prn [MEDICATION NAME] order dated 1/23/18 was continued with no specified duration for the order and no rationale other than resident request. An additional pharmacy recommendation dated 2/5/18 documented, (Resident #9) has a PRN order for an antidepressant, which has been in place for greater than 14 days without a stop date: [MEDICATION NAME] 7.5 mg prn [MEDICAL CONDITION]. This is in addition to a scheduled order for [MEDICATION NAME] 7.5 mg HS (at each bedtime) .Recommendation: On 1/19/18 resident refused discontinuing prn dose. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and the rationale for the extended time period. *Need to state a duration of therapy*. The physician responded to this recommendation stating, Recommendation is reasonable. However pt (patient) has decision making capacity and is adamant about med (medication) as is. There was no specified duration listed for the renewal of the prn order. Resident #9's care plan (revised 9/29/18) documented the resident used the [MEDICAL CONDITION] medication [MEDICATION NAME] for the treatment of [REDACTED]. On 2/20/19 at 1:00 p.m., the licensed practical nurse (LPN #1) caring for Resident #9 was interviewed about the prn [MEDICATION NAME]. LPN #1 stated Resident #9 requested the [MEDICATION NAME] occasionally when she was unable to sleep. LPN #1 stated the director of nursing that added the note on the bottom of the 2/5/18 pharmacy recommendation no longer worked at the facility. On 2/20/19 at 1:06 p.m., the resident's physician was interviewed about the prn [MEDICATION NAME] order. The physician stated the resident was already on the prn [MEDICATION NAME] when she took over her care. The physician stated the resident was very obsessed about her medications and did not want her medications changed. The physician stated the resident was administered scheduled [MEDICATION NAME] for treatment of [REDACTED].#9) thinks she needs that ([MEDICATION NAME]) to help her sleep. The physician stated that the prn order for [MEDICATION NAME] was not her preferred treatment for [REDACTED]. The physician stated she did not recall the pharmacy request to specify a duration for the therapy. The Nursing (YEAR) Drug Handbook on pages 985 describes [MEDICATION NAME] ([MEDICATION NAME]) as an antidepressant used for the treatment of [REDACTED]. These findings were reviewed with the administrator and director of nursing during a meeting on 2/20/19 at 5:15 p.m. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing (YEAR) Drug Handbook. Philadelphia: Wolters Kluwer, (YEAR).

Based on staff interview and facility document review it was determined that the facility staff failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, there was no RN (Registered Nurse) on site for eight consecutive hours on Saturday, 2/9/19. The facility as-worked schedule for the period covering 1/20/19 to 2/19/19 revealed that there was no RN (Registered Nurse) on site for any eight-hour shift on 2/9/19. The findings include: A review of the facility as-worked schedule for the period covering 1/20/19 to 2/19/19 revealed that there was no RN coverage for any eight hour shift on Saturday, 2/9/19. On 02/20/19 at approximately 3:56 p.m., an interview was conducted with ASM (administrative staff member) #1, the Administrator. During the interview, the facility as worked staffing sheet was reviewed. When asked who coordinates RN staffing, ASM #1 replied, I do. ASM #1 was then asked to identify any RN's that worked on the date of 2/9/19. ASM #1 replied, On, that day the RN had a personal day off and the DON (director of nursing) was on call. ASM #1 was asked if the DON was onsite for eight consecutive hours on the date of 2/9/19, ASM #1 replied, No, they did not come in that day but they were available by phone. On 02/20/19 at approximately 3:58 p.m., the facility policy on RN staffing was requested. On 02/20/19 at approximately 4:07 p.m., this surveyor was informed by ASM #1 the facility did not have a policy on RN staffing. On 02/20/19 at 5:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the Administrative Assistant, ASM #3, the Director of Nursing and RN #1, the Assistant Director of Nursing, were made aware of the above concerns. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure adequate supervision and failed to implement interventions to prevent falls per the plan of care for one of ten residents in the survey sample, Resident #3. The facility staff failed to ensure supervision and failed to place a tab alarm, while the resident was in a recliner, and Resident #3 got up, fell and broke her hip. The findings include: Resident #3 was admitted to the facility on [DATE] with a readmission on 4/9/15 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/16/15, coded the resident as being cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living, except eating in which she required supervision after set up assistance was provided. A review of the Significant Change in Status MDS assessment with an ARD of 1/24/15 coded Resident #3 as scoring a 9 out of 15 on the BIMS (brief interview for mental status) indicating she was moderately impaired for cognition. The resident was coded under Section G- Functional Status as requiring extensive assistance of one or more staff members for bed mobility, transfers, toilet use and personal hygiene. She was coded as requiring limited assistance with one person physically assisting for walking in room, corridor, and locomotion on and off unit. Section G0300. Balance During Transitions and Walking Coded Resident #3 under A. Moving from seated to standing position as not steady, only able to stabilize with human assistance. Under B. Walking (with assistive device if used) Resident #3 was coded as not steady, only able to stabilize with human assistance. Under J1900. Number of Falls Since Admission or Prior Assessment, Resident #3 was coded as having one fall - No injury. Und B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes resident to complain of pain., Resident #3 was coded a 1 (one fall with injury). The nurse's note dated, 3/31/15 at 11:13 p.m. documented, @ (At) 1930 (7:30 p.m.) client was sitting in her chair in the great room when she got up unassisted and started walking toward another chair. Client lost her balance, stumbled and fell on the floor. Upon assessment, ROM (range of motion) normal in all extremities except ROM very limited in right leg/hip and client c/o (complained of) severe pain, 10 of 10 (a pain scale of 0 - 10, 10 being the worse pain someone has ever been in) with movement. Client was given Norco (pain medication given for moderate to moderately severe pain) (1). Client c/o right foot numbness and inability to move her left (sic) leg/hip. Reassurance given and client encouraged to limit movement until further evaluation completed. (Name of Doctor) notified of incident and order given to transport client to hospital for evaluation of hip r/t (related to) possible fx (fracture). Paperwork completed and rescue squad transported client to (Name of Hospital) at 2015 (8:15 p.m.) .Emergency personnel updated on client's pain and reassurance given by emergency personnel for increased comfort measures enroute to hospital. POA (power of attorney) notified. Review of the care plan dated, 1/22/13, with a revision of the care plan on 2/10/15, documented, Focus: The resident has had an actual fall 2x (times) in past 3 months with no major injury noted due to unsteady gait and weakness. The Interventions: TAB alarm while in recliner. This intervention was dated initiated on 1/12/15 and created on 2/10/15. A physician order [REDACTED]. Review of the hospital discharge summary dated, 4/9/15, documented, Discharge Diagnosis: [REDACTED]. Acute on chronic kidney failure, Closed displaced fracture of right femoral neck. A request was made for the incident report. The incident report was provided but surveyor was not allowed to have a copy of it. The Incident/Accident Report dated, 3/31/15 at 19:30 documented the incident occurred in the facility great room. Resident's condition before incident/accident: Normal. Resident attempted to get up out of her recliner unassisted and fell . Landed primarily on R (right) hip with injury noted. Limited ROM in R leg noted. Otherwise full ROM noted. Neuro (neurological) status WNL (within normal limits). Resident transferred to (Initials of hospital) per MD (medical doctor) orders 12. Did CNA (certified nursing assistant) have all safety devices properly in place? Yes. The two CNA (certified nursing assistants) documented on the incident/accident report were no longer employed at the facility. The nurse on duty was contacted. An interview was conducted with RN (registered nurse) #3 on 1/21/16 at 10:58 a.m. RN #3 was asked to describe what happened the evening Resident #3 fell , RN #3 stated, She (Resident #3) was in the great room in the recliner. There was not a lot of activity going on in the great room. (Resident #3) attempted to stand up out of the recliner. I did not witness the fall. She called out for help. She was fairly alert and oriented but has some confusion. She was trying to get a magazine, I believe. When asked if the resident had a tab alarm on while in the chair, RN #3 stated, From what I can remember, it was not in use at the time of the fall. We had been instructed a few days before that to do without alarms. I guess we didn't update the care plan. The former DON (director of nursing) had instructed the staff to decrease the use of alarms and to monitor her (Resident #3) closely. When asked how far away the staff was at the time of the fall, RN #3 stated, The staff was at the nurse's station (approximately 25 - 30 feet away from the resident). An interview was conducted with ASM (administrative staff) #2, the DON on 1/21/16 at 11:26 a.m. The DON was asked to review the care plan in place at the time of the fall. When asked if a tab alarm should have been in place, the DON stated, If it's there (documented on the care plan) it should have been in place. The DON stated that the previous DON had an initiative to decrease the amount of alarms used at the facility. The DON was asked to provide evidence of the initiative and training of staff regarding it. An interview was conducted with the administrator on 1/21/16 at 11:57 a.m. He informed the survey team that there was no documentation of the plan to decrease alarms for residents. It was the former DON's initiative to decrease alarms in the facility. The facility policy, Falls: Policy and Procedure documented, Falls are a common source of injury and death among the elderly. It is the responsibility of all staff to assist in identifying risk factors and to carry out established plans to minimize falls. Licensed nursing staff will assess clients who experience falls, for injury and identification of new risk factors. Falls will be addressed on the client's care plan. The administrator and director of nursing were made aware of the concern for harm on 1/21/16 at 1:10 p.m. The administrator stated that the facility had identified falls as a concern and started a plan of action on it. The fall occurred under the leadership of the former administrator. He could not locate any action plan implemented by the previous administrator immediately after the fall. The current administrator stated he had identified falls as a concern one month after starting his position and implemented a plan of action. On 1/21/16 at approximately 2:30 p.m. the administrator and director of nursing presented credible evidence that a five point plan of correction had been put into place. The credible evidence included the following: A staff meeting In - Service date, 7/9/15 documented, CNA Updates & Inform (information): If your work is complete, you should be sitting and talking with the residents, not at the nurse's station. If you need to chart, try sitting in the great room at a table close to the recliner circle. Make it a habit to glance up and check on the residents frequently, at least between each resident. Plan of Action: Falls · Problem Identification: On November 12, 2015 the administrator and DON noted a problem with falls in this facility. · Goals: The Goal of this action plan is to eliminate any avoidable falls. · Education Provided: On January 7, 2016 staff meeting at 7:00 p.m., all staff were educated by (name of administrator) about falls and the basics of fall prevention. Items discussed were gait belts and their use, locking wheelchairs for transfers, and proper non-skid footwear use. · Interventions: All nursing assistants must have a gait belt with them at all times. Gait belts must be used on all transfers and ambulation for which they are appropriate. A falls committee will be researched and developed for future implementation. More education concerning falls and gait belts will be provided at the February 2016 staff meeting. · Date of Implementation: January 8, 2016 · Evaluation: This will be evaluated through our current QAPI (Quality Assurance Program Improvement) process and the falls committee once that is implemented. An interview was conducted with CNA #5 on 1/21/16 at 3:00 p.m. When asked how the staff prevents falls, CNA #5 stated, The first thing is the use of gait belts, using two people assist to walk clients. We have to remember to lock wheelchair prior to transfers. When asked if clients are to be left alone in the great room, CNA #5 stated, No, there always has to be a CNA in the great room when there are residents present. When asked how a CNA knows what fall interventions are in use for a particular resident, CNA #5 stated, First our nurse gives us report as does the off going CNA. We can check the care plan for the intervention. We have access to care plan through our charting application on the computer. An interview was conducted with CNA #6, the resident care services CNA, on 1/21/16 at 3:40 p.m. When asked how the facility prevents falls, CNA #6 stated, The first thing we do is always use a gait belt unless there is an exception that the DON has informed us of. When asked if motion alarms were used as a fall intervention, CNA #6 stated, The DON makes that determination. When asked where a CNA finds out what interventions are in place to prevent falls for a particular resident, CNA #6 stated, We have access to the care plan and it's our responsibility to read it for what interventions a resident may need. During the survey, no concerns were identified by observation or record review for falls. The staff was observed using gait belts. When the great room was observed with residents in the room, a staff member was always present. No further information was provided prior to exit. PAST NON - COMPLIANCE (1) <http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1c7ff5b9-6698-4e8c-9060-2abcd3fb0dcf> (2) Barron's Dictionary of Medical Terms for the Non - Medical Reader, 5th edition, Rothenberg and Chapman; page 281.