Every finding on record at NHC Healthcare, Columbia

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Time and Attendance Reports, staff screening logs, and interview, the facility failed to properly prevent and/or contain COVID-19 when 47 of 117 staff members (Housekeeping Staff #1, #2, #3, and #4, Dietary Staff #1, #2, #3, #4, #5, and #6, Maintenance Staff #1, Staff Secretary #1 and #2, Registered Nurse (RN) #1, #2, and #3, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, and #6, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and Nurse Aide (NA) #1) failed to complete screenings prior to working on 7 of 7 days (10/21/2021, 10/22/2021, 10/23/2021, 10/24/2021, 10/25/2021, 10/26/2021, and 10/27/2021) reviewed. This could have potentially affected the 95 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options could include .individual screening on arrival at the facility .before entering the facility. Review of the facility's policy titled, [Named Corporation] COVID-19 Plan, dated 7/1/2021, revealed .[Named Corporation] will screen each partner before each workday and each shift . Review of the Time and Attendance Reports and staff screening logs from 10/21/2021 - 10/27/2021, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 10/21/2021 - Housekeeping Staff #1; Dietary Staff #3 and #4; Maintenance Staff #1; Staff Secretary #1 and #2; RN #2; LPN #1, #3, #4, and #5; CNA #5, #8, #10, #11, #15, and #20. b. 10/22/2021 - Dietary Staff #3 and #4; Staff Secretary #1 and #2; RN #1, #2, and #3; LPN #5; CNA #2, #3, #4, #5, #6, #7, #8, #9; NA#1. c. 10/23/2021 - Housekeeping Staff #1; Dietary Staff #3, # 4, and #6; LPN #3 and #6; CNA #1, #3, #4, #6, #7, #9, #10, #11, #12, #18, #19, #21, #22, and #23. d. 10/24/2021 - Housekeeping Staff #1, #3, and #4; Dietary Staff #1 and #3; LPN #6; CNA #1, #4, #6, #7, #10, #11#, #12, and #14. e. 10/25/2021 - Dietary Staff #1, #4, #5, and #6; Staff Secretary #1; LPN #1, #2, and #5; CNA #5, #6, #8, #10, #11, #15, #17, #18, and #19. f. 10/26/2021 - Housekeeping Staff #1; Dietary Staff #1 and #2; Maintenance Staff #1; Staff Secretary #1; RN #3; LPN #1, #2, and #6; CNA #3, #4, #5, #8, #9, #10, #11, #13, #14, #15, and #16. g. 10/27/2021 - Housekeeping Staff #1 and #2; Dietary Staff #3; Staff Secretary Staff #1, RN #1; LPN #1 and #2; CNA #4, #5, #7, #8, #14, #15, and #24. Interview on 11/3/2021 at 5:12 PM, the Administrator confirmed the staff failed to screen prior to working. The Administrator was asked who was responsible for the staff screenings. The Administrator stated, .the Director of Nursing and myself do random audits .the supervisors ensure the staff screen prior to their shifts .we do in-services on screenings regularly .I'm not sure what is going on .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 2 of 3 sampled residents (Resident #73 and #77) reviewed for an indwelling urinary catheter. The findings include: Review of the facility's undated policy titled, CATHETER CARE, INDWELLING (MALE AND FEMALE), revealed .Catheter care will be provided using approved technique in order to decrease the risk of the catheter-associated urinary tract infection .clean perineal area from front to back, using a clean wipe for each of the areas to be cleaned (1 wipe per swipe) . Review of the facility's undated policy titled, Perineal Care, revealed .To provide cleanliness and comfort to the patient, prevent infections, and skin irritation .For a male patient .Wet washcloth and apply soap or skin cleansing agent .Wash perineal area starting with the urethra and working outward .Retract foreskin of the uncircumcised male .Wash and rinse urethral area using a circular motion .Rinse perineal area in same order, using fresh water and a clean washcloth . Review of the facility's undated procedure titled, CNA [Certified Nursing Assistant] Pericare Check Off, revealed .Cleanse the head of the penis with washcloth, using motions away from the urinary meatus .Using clean cloth, rinse in the same manner .Dry thoroughly .If male pt [patient] is uncircumcised, the foreskin must be retracted to cleanse the head of the penis . Review of the medical record, revealed Resident #73 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] and the quarterly MDS dated [DATE], revealed Resident #73 had an indwelling urinary catheter and required extensive staff assistance for Activities of Daily Living (ADLS). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 11/3/2021 at 1:43 PM, revealed Resident #73 had an indwelling urinary catheter. CNA #14 gathered her supplies, washed her hands, filled the basin with water, donned gloves, poured soap into the water, pulled the foreskin back slightly, exposing only the tip of the penis, and washed the tip of penis. CNA #14 failed to wash the entire head of the penis and did not rinse or dry the area after washing. CNA #14 grabbed the catheter with her left hand, washed the length of the catheter with the soapy water, failed to rinse the catheter, and then dried the catheter. During an interview on 11/3/2021 at 1:54 PM, the CNA Instructor confirmed that CNA #14 should have pulled the foreskin all the way back, washed, rinsed, and dried the penis. The CNA Instructor confirmed that CNA #14 should have washed, rinsed, and dried the catheter. Review of the medical record, revealed Resident #77 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS dated [DATE] and the quarterly MDS dated [DATE], revealed Resident #77 had an indwelling urinary catheter and required extensive staff assistance for ADLs. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 11/3/2021 at 2:23 PM, revealed CNA #23 donned her gloves, applied liquid soap solution to the washcloth, washed Resident #77's urinary catheter tubing using a back-and-forth motion up and down one side of the catheter. Resident #77's catheter tubing was lying against her left upper thigh and CNA #23 did not lift the tubing to cleanse the length or around the catheter tubing. CNA #23 failed to rinse the soapy solution from the urinary catheter tubing and proceeded to dry the tubing. CNA #23 performed perineal care with the same washcloth, folding the washcloth within itself wiping back and forth. The was cloth was noted with a brown stain during each swipe of the washcloth. CNA #23 failed to change out the soiled washcloth with a clean washcloth during perineal care. CNA #23 positioned Resident #77 on her right side and continued to use the same washcloth wiping back and forth during care. During an interview on 11/3/2021 at 2:28 PM, the CNA Instructor confirmed CNA #23 did not properly perform catheter and perineal care. The CNA Instructor stated, .during peri care [perineal] and catheter care .she went over the same area multiple times from dirty to clean with the same dirty wash cloth, the washcloth had feces on it .she washed the peri [perineal] area and catheter and did not rinse, then she dried the catheter and the peri area .she failed to rinse the catheter .the catheter itself she went back and forth .up and down the catheter .she did not grip or secure the catheter and wiped down the length of the catheter .the catheter was lying against the residents leg .she cleaned one side of the catheter .when she turned her over on the on the back side .she wiped back and forth multiple times with the dirty washcloth .she should have wiped from front to back and changed the cloth with each swipe .she should have grabbed the catheter 2-3 inches from the urethra .hold the catheter and with a soapy rag [wipe] down the catheter 2 times .rinse 2 times and then pat and dry.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 5 of 9 medication storage areas (A/B Hall Medication Room, B Hall Cart, C Hall Cart, A/B Hall Cart, and the Treatment Cart) when the facility had open and undated, and expired medications in the medication and treatment carts. The findings include: Review of the facility's policy titled, MEDICATION STORAGE IN THE FACILITY, dated 1/1/2019, revealed .Outdated .are removed from inventory, disposed of according to procedures for medication disposal . Observation of the A/B Medication Room on 11/1/2021 at 12:05 PM, revealed 1 opened and undated vial of [MEDICATION(S)] vaccine in the refrigerator. During an interview on 11/1/2021 at 12:05 PM, Licensed Practical Nurse (LPN) #5 confirmed that the vaccine should have been dated when opened. Observation in the B Hall Cart on 11/1/2021 at 12:15 PM, revealed 1 opened and undated vial of [MEDICATION(S)]. During an interview on 11/1/2021 at 12:15 PM, LPN #8 confirmed that the insulin should be dated when opened. Observation of the C Hall Cart 11/1/2021 at 12:22 PM, revealed 2 vials of [MEDICATION(S)] with an expiration date of 8/2021. During an interview on 11/1/2021 at 12:22 PM, LPN #9 confirmed that the expiration date was 8/2021 on the 2 vials of [MEDICATION(S)]. Observation of the A/B Hall Cart on 11/1/2021 at 12:35 PM, revealed 1 open and undated Novolog Insulin pen and 1 opened and undated bottle of [MEDICATION(S)]. During an interview on 11/1/2021 at 12:35 PM, CNA #10 confirmed that the insulin pen should be dated when opened. Observation of the Treatment Cart on 11/2/2021 at 1:49 PM, revealed 1 bottle of [MEDICATION(S)] packing strip with an expiration date of 10/2020. During an interview on 11/2/2021 at 1:49 PM, the Director of Nursing (DON) confirmed that there should not be expired items in the treatment cart. During an interview on 11/2/2021 at 2:19 PM, the DON confirmed that there should not be any open and undated or expired medications in the medication carts.

Based on medical record review, observation, and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 3 of 18 sampled residents (Resident #36, #37, and #100) reviewed. The findings include: Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record, revealed Resident #36 did not have a Baseline Care Plan completed within 48 hours of admission that addressed the initial goals and needs of the resident. Review of the medical record, revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #37 did not have a Baseline Care Plan completed within 48 hours of admission that addressed the initial goals and needs of the resident. Review of the medical record, revealed Resident #100 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #100 did not have a Baseline Care Plan completed within 48 hours of admission that addressed the initial goals and needs of the resident. During an interview on 11/3/2021 at 3:25 PM, the MDS (Minimum Data Set) Coordinator confirmed Baseline Care Plans should be completed within 48 hours of a resident's admission.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 3 of 5 nurses (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1 and #2) failed to perform hand hygiene, failed to clean an oral inhaler, and failed to rinse a Percutaneous Endoscopic Gastrostomy (PEG) tube syringe after use for 3 of 5 sampled residents (Resident #142, #40, and #291) observed during medication administration. The findings include: 1. Review of the facility manual titled, INFECTION CONTROL MANUAL, dated 12/1998, showed that hand hygiene should be performed after removing gloves. 2. Observation in the resident's room on 1/7/20 at 8:37 AM, showed RN #1 administered medications to Resident #142. RN #1 moved the over bed table, pull the privacy curtain, adjusted pillows on the bed, and reached in her pocket and donned gloves. RN #1 did not perform hand hygiene between touching objects in the room and donning her gloves. 3. Observation of RN #1 in the C Hall outside of room [ROOM NUMBER] on 1/7/20 at 8:45 AM, showed RN #1 dropped Resident #142's oral inhaler on the floor. RN #1 picked up the oral inhaler, put it in a labeled bag and placed it in the medication cart. RN #1 did not clean the inhaler before returning it back to the medication cart. 4. Observation in the resident's room on 1/7/20 at 9:00 AM, showed LPN #1 administered medications through a PEG tube to Resident #40 and placed the syringe back into the plastic bag. LPN #1 did not rinse the syringe before placing it into the bag. 5. Observation in the resident's room on 1/7/20 at 10:12 AM, showed LPN #2 administered oral medications to Resident #291, removed an old [MEDICATION NAME] from his right shoulder, and applied a new patch to his left shoulder. LPN #2 removed her gloves, donned clean gloves, and administered an injection to his left lower abdomen. LPN #2 did not perform hand hygiene after the removal of her gloves and before donning clean gloves. 6. During an interview conducted on 1/8/20 at 10:30 AM, the Director of Nursing (DON) was asked if hand hygiene should be performed before and after donning gloves. The DON stated, Yes. The DON was asked if an oral inhaler was dropped on the floor, should it be cleaned before placing it in a storage bag and in the medication cart. The DON stated, Yes. The DON was asked if PEG syringes should be cleaned after use. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 7 (C Hall Medication Cart) medication storage areas. The findings include: 1. The facility policy titled, MEDICATION STORAGE IN THE FACILITY, dated 6/2016 documented, .Medication rooms, carts, and medications supplies are locked when not attended by persons with authorized access . 2. Observation in the C Hall outside of room [ROOM NUMBER] on 1/7/20 at 4:20 PM, showed an unlocked and unattended medication cart. During an interview conducted on 1/8/20 at 7:50 AM, the Director of Nursing (DON) was asked if a medication cart should be left unlocked and unattended. The DON stated, No.

Based on facility policy review, observation and interview, the facility dietary department failed to serve hot food at or above 135 degrees Fahrenheit (F) and cold food at or less than 41 degrees F. The findings included: Review of facility policy, Safety & (and) Sanitation Best Practice Guidelines, revised 1/2011 revealed .Time and Temperature Control .Hot food will be held at 135 degrees F or above .Cold food will be held at 41 degrees F or lower . Observation on 2/6/17 beginning at 11:25 AM in the dietary department of the resident mid-day meal trayline service, revealed 1 tray delivery cart including 2 pureed texture meals had left the dietary department for tray distribution to the residents. Continued observation revealed milk cartons stacked in a container of ice with no ice in contact with the 3 cartons of milk on the upper layer. Further observation revealed the Dietary Manger obtained a temperature of 116.5 degrees F for the pureed pork loin stored in the steamtable and 47 degrees F for milk in the upper layer not in contact with the ice. Observation on 2/7/17 at 7:20 AM in the dietary department of the resident morning meal trayline service revealed milk cartons stacked in a container of ice with no ice in contact with the 5 cartons of milk on the upper layer. Further observation revealed the Registered Dietitian obtained a temperture of 46 degrees F for the milk on the upper layer not in contact with the ice. Interview with the Dietary Manager and the Registered Dietitian on 2/6/17 at 11:35 AM and the Registered Dietitian on 2/7/17 at 7:30 AM in the dietary department confirmed the facility failed to maintain the pureed pork loin at or above 135 (140) degrees F and the milk at or less than 41 (45) degrees F. Interview with the Dietary Manager on 2/8/17 at 4:39 PM in the classroom confirmed the facility failed to follow the facility policy to maintain hot food at or greater than 135 degrees F and maintain cold food at or less than 41 degrees F.

Based on medical record review and interview, the facility failed to accurately assess the [MEDICAL TREATMENT] status for 1 Resident (#26) of 2 residents reviewed for [MEDICAL TREATMENT]. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility failed to accurately assess the [MEDICAL TREATMENT] services provided. Medical record review of a Physicians Order dated 3/5/15 revealed [MEDICAL TREATMENT] at (named) [MEDICAL TREATMENT] clinic. Interview with the MDS Coordinator responsible for the accuracy of the MDS assessment,on 2/8/17 at 2:00 PM at the AB nurses station confirmed the facility failed to accurately address the [MEDICAL TREATMENT] status for the resident on the 11/11/16 Quarterly MDS. Interview with the Director of Nursing (DON) on 2/8/17 at 2:25 PM at the AB nurses station confirmed the facility failed to accurately address the [MEDICAL TREATMENT] status of Resident #26.

Based on facility protocol review, medical record review, observation and interview, the facility failed to provide the treatment as ordered for an unstageable pressure ulcer to the coccyx of 1 Resident (#156) of 5 residents reviewed for pressure ulcers. The findings included: Review of facility policy How to Perform a Dressing Change, undated revealed, .Review the physician's orders [REDACTED]. Review of facility Documentation Guidelines revealed, Routine .Treatments are given only on orders of a physician . Medical record review revealed Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was admitted to the facility with 9 unstageable pressure ulcers and 3 suspected deep tissue injury wounds. Treatment included pressure ulcer care,application of ointment/medications and non surgical dressings. Medical record review of the physician's orders [REDACTED].Clean unstageable wound to Coccyx with normal saline pat dry apply [MEDICATION NAME] (foam dressing that gels on contact) and cover dsg (dressing) qod (every other day) . Observation of wound care with the Wound Care Nurse with the MDS nurse present, on 2/8/17 at 10:40 AM in Resident #156's room, revealed the Wound Care Nurse was providing pressure ulcer treatment to the resident's coccyx. Continued observation revealed the Wound Care Nurse applied Santyl (an enzyme prescription ointment used to clean wounds to aid in healing) to the resident's coccyx before placing a dressing over the pressure ulcer. Interview with the Wound Care Nurse on 2/8/17 at 11:30 AM at the AB Nurse Station confirmed she applied Santyl ointment instead of [MEDICATION NAME] to the resident's coccyx during wound care treatment. Continued interview confirmed the Wound Care Nurse failed to apply the correct treatment for [REDACTED]. Interview with the Director of Nursing (DON) on 2/8/17 at 4:00 PM in the DON's office confirmed the facility failed to provide the ordered treatment for [REDACTED].#156.

Based on medical record review, observation, and interview the facility failed to provide the treatment as ordered for an unstageable pressure ulcer to the coccyx of 1 Resident (#156) of 5 residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was admitted to the facility with 9 unstageable pressure ulcers and 3 suspected deep tissue injury wounds. Treatment included pressure ulcer care, application of ointment/medications, and non surgical dressings. Medical record review of the Care Plan dated 1/3/17 revealed a problem of Skin related to multiple pressure wounds. Approaches included, .Provide wound care per orders to following wounds: Coccyx-unstageable wound . Medical record review of the physician's orders [REDACTED].Clean unstageable wound to Coccyx with normal saline pat dry apply [MEDICATION NAME] (foam dressing that gels on contact) and cover dsg (dressing) qod (every other day) . Observation of wound care with the Wound Care Nurse with the MDS nurse present, on 2/8/17 at 10:40 AM in Resident #156's room revealed the Wound Care Nurse was providing pressure ulcer treatment to the resident's coccyx. Continued observation revealed the Wound Care Nurse applied Santyl (an enzyme prescription ointment used to clean wounds to aid in healing) to the resident's coccyx before placing a dressing over the pressure ulcer. Interview with the Wound Care Nurse on 2/8/17 at 11:30 AM at the AB Nurse Station confirmed she applied Santyl ointment instead of [MEDICATION NAME] to the resident's coccyx during wound care. Continued interview confirmed the Wound Care Nurse failed to follow the care plan for treatment of [REDACTED].#156. Interview with the Director of Nursing (DON) on 2/8/17 at 4:00 PM in the DON's office confirmed the facility failed to follow the care plan for treatment of [REDACTED].#156.

Based on observation and interview, the facility failed to post the nurse staffing information on a daily basis for 2/4/17 and 2/5/17. The findings included: Observation on 2/6/17 at 9:05 AM in the front lobby of the facility, during the initial tour, revealed the facility failed to post the nurse staffing information for 2/6/17. Interview with Licensed Practical Nurse (LPN) #1 on 2/6/17 at 9:20 AM at the AB nurse's station confirmed the nurse staffing information was not posted for 2/4/17 and 2/5/17. Continued interview with LPN #1 confirmed the daily nurse staffing information for 2/6/17 was posted by 10:00 AM. Interview with the Director of Nursing (DON) on 2/7/17 at 1:30 PM in the classroom confirmed the facility failed to post the nurse staffing information for 2/4/17 and 2/5/17.

Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served in a sanitary manner as evidenced by 6 of 8 dietary staff members (Dietary staff members (DSM) #1, 2, 3, 4, 5, and 6) had exposed hair from a hair restraints, expired food items, opened, unlabeled and undated food items, scoops in bins, dirty shelves, and a dented can. The facility had a census of 85, with 83 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's .HYGIENIC & (and) SAFETY PRACTICES . policy documented, .Hair Restraints for Dietary Partners . shall wear hair restraints . worn to . keep their hair from contacting exposed food . a. Observations in the kitchen on 2/1/16 beginning at 10:30 AM, revealed DSM #1 and 2 wore a hair restraint, but their hair was not completely covered. b. Observations in the kitchen on 2/2/16 at 4:55 PM, revealed DSM #3, 4 and 5 wore a hair restraint, but their hair was not completely restrained. c. Observations in the kitchen on 2/4/16 at 11:22 AM, revealed DSM #1 wore a hair restraint, but her hair was not completely restrained. d. Observations in the dining room on 2/3/16 at 11:32 AM, revealed DSM #6 wore a hair restraint while serving behind the buffet line and her hair was not completely covered. Interview with the Certified Dietary Manager (CDM) and Registered Dietician (RD) on 2/4/16 at 11:50 AM, in the large conference room, the CDM was asked if hair should be completely covered by hair restraints. The CDM stated, Right. 2. The facility's .Safety & Sanitation Best Practice Guidelines . policy documented, .Cooked Meats . Storage Time 7 days . Special Instructions . covered securely, date with use by date . Canned Fruits, opened . covered securely, date with use by date . Commercially prepared Meat . Salads . chicken . Special Instructions . covered securely; date with use by date . A. Observations in the kitchen on 2/1/16 beginning at 10:30 AM, revealed the following: a. Nine cartons of expired fat free chocolate milk, dated 1/31 and 1 carton of expired fat free chocolate milk, dated 1/24 in the reach-in cooler. b. Eight cartons of expired fat free chocolate milk, dated 1/31 in the walker-in cooler. c. A container of expired tomato sauce, not labeled and dated 1/22/16 in the walk-in cooler. d. A container of a white powder substance sitting on a shelf that was not labeled or dated. e. Three large plastic bins: 1 bin labeled corn meal with a scoop in it, 1 bin labeled sugar, with a scoop in it, and 1 bin labeled oatmeal and none of these were dated. f. An opened bag of chicken tenders, not labeled or dated in the reach-in freezer. g. An opened bag of french fries with 2 sides torn, not sealed, labeled or dated in the reach-in freezer. h. An opened bag of tater tots, not labeled or dated in the reach-in freezer. i. An opened package of bacon, not labeled or dated in the reach-in freezer. j. An opened bag of spicy fries, not labeled or dated in the reach in-freezer. k. Five clear plastic containers on the wall labeled Raisin Bran, Frosted Flakes, Cheerios, Rice Krispies, and Corn Flakes not dated. l. A container of food with a lid not secured, not labeled, in the walk-in cooler. The CD identified the food as chicken salad. m. A plastic container of fruit with a lid not secured and not labeled in the walking - cooler. The CD identified the fruit as as pineapple. Interview with the Clinical Dietician (CD) on 2/1/16 at 10:33 AM, in the kitchen, the CD was asked if the containers should be labeled. The CD stated, Uh-huh. The CD confirmed the milk and tomato sauce were expired. Interview with DSM #7 on 2/1/16 at 10:34 AM, in the kitchen, DSM #7 was asked what was in the container. DSM #7 stated, Flour. DSM #7 was asked if it should be labeled and dated. DSM #7 stated, Supposed to be. B. Observations in the kitchen on 2/2/16 beginning at 4:55 PM, revealed the following: a. Three large plastic bins: 1 bin labeled corn meal with a scoop in it, 1 bin labeled sugar, with a scoop in it, and 1 bin labeled oatmeal and none were dated. b. A bag of french fries opened, not labeled or dated in the reach-freezer. c. A carton of no sugar ice cream opened and not dated in the reach-in freezer. d. A bag of sweet potato fries opened, not sealed and not labeled or dated in the reach-in freezer. e. An opened bag of tater tots with 3 open areas on the bag, not sealed, labeled or dated in the reach-in freezer. f. An opened box of bratwurst not sealed, labeled or dated in the reach-in freezer. g. Two glasses of milk with an A on the lid, not labeled or dated in the reach-in cooler. h. Seven glasses of thickened milk, not labeled or dated in the reach-in cooler. i. Four glasses of thickened tea, not labeled or dated in the reach-in cooler. j. Seven glasses of thickened orange juice, not labeled or dated in the reach-in cooler. k. A tray of jello, not labeled in the reach-in cooler. l. Two metal containers of cooked sausage and bacon mixed together, not labeled in the reach-in cooler. m. A metal pan of expired tomato sauce not labeled and dated 1/20/16 in the reach-in cooler. n. A metal pan with gravy, not labeled in the reach-in cooler. o. Six trays of bacon, a tray of sausage and a half (1/2) tray of biscuits, not labeled or dated in the reach-in cooler. p. Four bowls with lids on them in the kitchen, not dated or labeled. The CDM was unsure of the contents. q. Five clear plastic containers on the wall labeled Raisin Bran, Frosted Flakes, Cheerios, Rice Krispies, and Corn Flakes not dated. r. A container of expired tomato sauce not labeled and dated 1/22/16 in the walk-in cooler. s. A container of pineapple, not labeled and unable to read the date in the walk-in cooler. t. A container of chicken salad with an unsecured lid, not labeled in the walk-in cooler. u. The milk cooler had dirty shelves with a dried substance on the shelves. The CDM took her fingernail and scratched a flaky substance off the shelf. Interview with the CDM on 2/2/16 at 4:58 PM, in the kitchen, the CDM was asked if the shelves were dirty in the milk cooler. The CDM stated, Yeah, I can clean them. Interview with the CDM and RD on 2/4/16 at 11:50 AM, in the large conference room, they were asked if food should be labeled according to the policy. The RD shook her head yes. The CDM was asked would you expect bins to have scoops in them. The CDM stated, Not have scoops in them. 3. Observations in the kitchen on 2/2/16 at 5:30 PM, revealed a dented can of Ensure in the walk-in cooler. Interview with the CDM on 2/2/16 at 5:30 PM, in the walk-in cooler, the CDM was asked if there was a dent in the can. The CDM stated Yes. The CDM was asked if it needed to be in the cooler. The CDM stated, No, (should be) in a box in my office.

Based on medical record review and interview, the facility failed to honor residents' choices for 4 of 15 (Residents #8, 24, 32 and 42) sampled residents interviewed regarding choices. The findings included: 1. Review of the facility's BATH, SHOWER policy documented, Designated partner will perform shower on a regular basis . 2. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 12/26/15 documented a problem of Activities of Daily Living (ADL) with approaches that included staff to assist with all bathing, dressing and hygiene needs daily. An annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 13, which indicated no cognitive impairment, with a daily preference for choosing between a tub bath, shower, bed bath or sponge bath as very important to Resident #8. Interview with Resident #8 on 2/3/16 at 6:30 PM, in her room, Resident #8 was asked how many showers she usually got in a week. Resident #8 stated, Some weeks I don't get any, and some weeks I get 1. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 60 day MDS assessment dated [DATE] documented a BIMS score of 13, which indicated no cognitive impairment. Resident #24 required physical help in part of bathing activity and one person physical assist. Interview with Resident #24 on 2/1/16 at 4:06 PM, in his room, Resident #24 was asked do you choose how many times a week you take a bath or shower. Resident #24 stated, No. I got a shower on Saturday and if I ask during the week they say, 'I don't have time or will have to wait until another day'. Resident #24 was asked whether you choose to take a shower, tub, or bed bath. Resident #24 stated, No, would like a shower 2 or 3 times a week. Interview with Certified Nursing Assistant (CNA) #3 on 2/3/15 at 2:25 PM, at the nurses' station, CNA #3 was asked if Resident #24 gets a shower. CNA #3 stated, Yes. CNA #3 was asked on what days. CNA #3 stated, Wednesday and Sunday. Interview with the Unit Manager (UM) on 2/3/15 at 2:32 PM, at the nurses' station, the UM was asked who was assigned to Resident #24 today. The UM stated, (Named CNA #4). The UM was asked if she had any documentation that resident #24 had a shower today. The UM stated, No. The UM was asked if there was any documentation that a shower had been offered. The UM stated, No, ma'am. Interview with Licensed Practical Nurse (LPN) #2 on 2/3/15 at 3:05 PM, at the nurses station, LPN #2 was asked if Resident # 24 received a shower today. LPN #2 stated, I don't think so. Interview with Resident #24 on 2/3/15 at 3:15 PM, in his room, Resident #24 was asked if he received a shower today. Resident #24 stated, No,ma'am. Resident #24 was asked if he was offered a shower today. Resident #24 stated, No, ma'am. Interview with the UM on 2/3/16 at 4:30 PM, in the Social Service's office, the UM was asked if this is the sheet (the daily CNA assignment sheet given to the surveyor earlier) used for residents in regards to baths and showers. The UM stated, This is the sheet. The UM verified Resident #24's shower days are Wednesday and Saturday. Interview with CNA #4 on 2/3/16 at 5:25 PM, in the conference room, CNA #4 was asked how often Resident #24 received a shower. CNA #4 stated, Showers on Wednesday and Saturday. CNA #4 was asked if Resident #24 received a shower today (Wednesday). CNA #4 stated, No, he didn't. CNA #4 was asked if he offered Resident #24 a shower today. CNA #4 stated, No, I didn't. 4. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 1/7/16 revealed a problem of cognitive deficits with a goal that Resident #32 will be out of her room interacting with others such as care givers, family, peers, on a daily basis to encourage cognitive stimulation through approaches to include assist to and from group functions of choice. An annual MDS dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment, with a daily preference for for activities as somewhat important to do things with groups of people. Interview with Resident #32 on 2/2/16 at 9:21 AM, in her room, Resident #32 she was asked if she can choose when to get up in the mornings. Resident #32 stated, Not this morning. Today, I wanted to go to exercise (group activity) and I told her (CNA) that I wanted to get up and go to exercise, but she didn't get me up in time. It starts at 10. She (CNA) never came back to get me up. Interview with CNA #2 on 2/2/16 at 9:40 AM, on the D hall, CNA #2 was asked if Resident #32 asked her to get up and go to exercise. CNA #2 stated, Yes, but I had an emergency with another resident and she had a BM (bowel movement) and I had to clean her up. Observations in the dining room TV area on 2/2/16 at 10:45 AM, revealed Resident #32 sitting in her wheelchair with a small group of residents. Music was playing. Interview with Resident #32 on 2/2/16 at 5:35 PM, Resident #32 was asked if she went to activities this morning. Resident #32 stated, They (staff) got me to activities about 10:30 AM, but I missed the exercise (class). It's from 10 to 10:30. The CNA came in and told me that she had to clean another lady up that had a BM (didn't go to exercise class). 5. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 1/27/16 documented a problem of ADL with approaches to include staff to assist with bathing, dressing, grooming. Interview with Resident #42 (Resident Council member) on 2/3/16 at 3:45 PM, in Resident #42's room, Resident #42 stated, Also, I am lucky if I get 1 shower a week. I asked the tech (CNA) today if I could get a shower. She said, 'I will go and check to see if it's your shower day today' but she never came back to me. So, I assumed it must not have been my shower day today. 6. Interview with the Director of Nursing (DON) on 2/3/16 at 5:12 PM, in the conference room, the DON was asked what prompted the new shower trial schedule. The DON stated, The department heads do weekly rounds, and I noticed people weren't going down there (to the shower) as often as they should. No one told me, I just noticed it. This is just a trial. I am doing it on this side (halls C and D) first to see if it helps. The DON was asked if she expected the staff to give residents showers on their shower days. The DON stated, Yes, they should. The DON was asked if a resident asked to have a shower on a day that is not their scheduled shower day, does she expect the staff to give them a shower. The DON stated, Yes, they should get a shower when they ask for one.

Based on medical record review, observation, and interview, 1 of 7 nurses (Registered Nurse (RN) #1) failed to notify the physician of elevated blood sugar results. The findings included: Medical record review revealed Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog 100 units/ml (milliliter) vial . Administer SSI (sliding scale insulin) Sub-Q (subcutaneous) AC (before meals) & (and) HS (at bedtime) as follows: 401- (to) 450= (amount of insulin to be administered) 12 units and call MD (medical doctor) . Observations in Resident #127's room on 2/1/16 beginning at 5:00 PM, revealed RN #1 performed an accucheck with a blood glucose of 402. RN #1 waited until trays arrived before administering insulin to this resident. At 5:58 PM, RN #1 performed another accucheck on this resident because it had been more than 30 minutes since the previous accucheck, with a result of 442. RN #1 did not notify the physician of the elevated blood sugar. Interview with RN #1 on 2/3/16 at 4:35 PM, at the AB nurses' station, RN #1 was asked if she had called the physician about Resident #127's elevated blood sugars on 2/1/16. RN #1 stated, No ma'am, his is over 450 that we call, want me to show you (went to computer and revealed Resident #127's Medication Administration Record [REDACTED]. No I did not (notify the MD).

Based on medical record and interview, the facility failed to accurately assess 1 of 20 (Resident #53) sampled residents for medications of the 32 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Pathological Fracture. The significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #53 received Antipsychotic, Antianxiety and Antidepressant medications 7 of 7 days and Antibiotic medications 0 of the 7 days. The Medication and Treatment Administration Records for January 2016 documented: a. Ziprasidone (Antipsychotic) was documented as administered on 1/9/16, 1/11/16, 1/12/16, 1/13/16, 1/14/16, and 1/15/16 (6 of 7 days). b. [MEDICATION NAME] (Antianxiety) was documented as administered 1/9/16 (1 of 7 days). c. [MEDICATION NAME] (Antidepressant) was documented as administered on 1/9/16, 1/11/16, 1/12/16, 1/13/16, 1/14/16, and 1/15/16 (6 of 7 days). d. [MEDICATION NAME] (Antibiotic) was documented as administered on 1/15/16 (1 of 7 days). Interview with the MDS Coordinator on 2/3/16 at 9:20 AM, in the MDS office, the MDS Coordinator was asked if the significant change MDS dated [DATE] should be coded as antipsychotic 6 days, antianxiety 1 day, antidepressant 6 days, and antibiotic 1 day. he MDS Coordinator stated, Yes ma'am. I will modify it. It has already been transmitted.

Based on medical record review, observation, and interview, the facility failed to follow care plan interventions for nutrition for 1 of 19 (Resident #72) sampled residents of the 32 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 12/25/15 documented, .PROBLEM . Nutrition/hydration: (Named Resident #72) is at risk for alteration in nutrition . Serve food quickly - pt (patient) may leave the dining room if not served . Observations in the dining room on 2/3/16 beginning at 5:20 PM, revealed 24 residents were being served. Residents had been served trays, while Resident #72 was wheeling himself about in the dining room. Resident #72 wheeled himself out of the dining room, and down the A hall. There were dependent diners (residents who need assistance eating) seated at a separate table in the rear of the dining room. As Certified Nursing Assistant (CNA) #1 retrieved a tray from the cart to serve to one of the dependent residents, CNA 1 stated, Where did (Named Resident #72) go to? As Licensed Practical Nurse (LPN) #1 retrieved Resident #72's tray from the cart. LPN #1 stated, Where is (Named Resident #72)? CNA #1 stated, I will go get him. At that time, Resident #72 was at the edge of the A hall. CNA #1 stated, Well there you are. CNA #1 served Resident #72's tray with the other dependent diners. Resident #72 was the 23rd resident served of the 24 residents in the dining room. The staff did not serve Resident #72's tray quickly, as care planned. Interview with the Director of Nursing (DON) on 2/3/16 at 6:35 PM, in front of the C/D nurses' station, the DON was asked how the staff would know what the care plan interventions are. The DON stated, They have care approach cards in their closets, and they (staff) should be reporting off to each other. The DON was told the situation in the dining room, and she confirmed Resident #72 should have been served timely.

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention and Treatment quick reference guide, policy review, medical record review and interview, the facility failed to conduct a weekly pressure ulcer assessment for 1 of 3 (Resident #22) sampled residents reviewed of the 5 residents with a pressure ulcer. The findings included: The NPUAP Prevention and treatment of [REDACTED].Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly . Document the results of all wound assessments . The facility's pressure ulcer management documented, .3. Weekly a. Wound assessments are documented using the Pressure Ulcer Progress Note . Medical record review revealed Resident #22 was admitted with [DIAGNOSES REDACTED]. A weekly wound assessment record revealed the following: a. Wound #1 - Stage 3 - Right Ischium/Buttocks - admitted with. b. Wound #2 - Stage 3 - Left Ischium/Buttocks - admitted with. c. Wound #3 - Unstageable - Sacrum - admitted with. d. Wound #4 - Stage 3 - Lower Right Ischium/Buttocks - admitted with (same as Wound #1 and became a separate wound on 12/15/15) There were no weekly pressure ulcer assessments documented on wounds #1, 2, 3 or 4 for the week of 1/24/16 through 1/30/16. Interview with the Director of Nursing (DON) on 2/3/16 at 9:55 AM, in the conference room, the DON stated, Wound #1 and 4 used to be 1 wound but they separated into 2 back in December. Interview with the DON on 2/3/16 at 3:01 PM, in the conference room, the DON was asked if she expected her staff to do weekly wound assessments on Resident #22. The DON stated, Yes, it's expected.

Based on policy review, observation and interview, it was determined the facility failed to ensure food was protected from physical contaminates and other sources of contamination as evidenced by 8 of 8 unauthorized persons (Environmental Services Director, Nurse #1, Maintenance Director, Certified Nursing Assistant (CNA) #1, 2, 3, Recreational Assistant #1, and Physical Therapy (PT) Director) entered the kitchen without a hair net and/or beard covering which could have affected 86 of the 89 residents in the building. The facility had 2 residents currently under isolation precautions. The findings included: 1. Review of the facility's "HYGIENIC & (and) SAFETY PRACTICES" policy documented, "...Effective personal hygienic and safety practices are essential in preventing food contamination. All Dietary partners must have an understanding of sanitation guidelines and put into practice those guidelines in order to provide a safe product for all customers... GUIDELINES... 3. Hair Restraints for Dietary Partners... Dietary partners shall wear hair restraints such hats, hair coverings, or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles..." 2. Observations in the kitchen on 12/8/14 at 11:10 AM, revealed the Environmental Services Director obtained 2 cartons of milks from the kitchen serving area, as Nurse #1 was leaving the serving area. Each of these employees did not have a hair restraint on. There was a sign in the service hall at the door prior to entering the kitchen at the serving line stating, "Entering Service Area No Hair Restraint Required", then a sign in the kitchen at the walking area just prior to entering the area on the other side of the tray line stating, "Entering Production Area Hair Restraints are Required Beyond This Point". This sign also was at the doorway to dish room in the service hall stating, "Entering Production Area Hair Restraints are Required Beyond This Point". 3. Observations in the kitchen on 12/8/14 at 12:24 PM, revealed the Maintenance Director standing in the kitchen at the serving line without a hair restraint on, conversing with the cook, as CNA #1 entered this area without a hair restraint on. 4. Observations in the kitchen on 12/9/14 at 12:34 PM, revealed CNA #2 and CNA #3 were standing in the kitchen at the serving line obtaining a tray without hair restraints on. 5. Observations in the kitchen on 12/9/14 at 5:25 PM, revealed Recreational Assistant #1 entered the kitchen at the serving line to obtain a tray, and was not wearing a hair restraint. 6. Observations in the kitchen on 12/10/14 at 7:55 AM, revealed the PT Director standing in the kitchen in front of the serving line without a hair restraint on. 7. During an interview in the kitchen on 12/10/14 at 8:10 AM, the Dietary Manager (DM) was asked about the staff entering the kitchen without hair restraints. The DM stated, "I know, have changed their policy and have it separated between production area and service area. I know has been a problem in the past." The DM confirmed the staff entered the kitchen without hair restraints on.

Based on policy review, personnel record review, observation and interview, it was determined the facility failed to ensure 1 of 5 (Nurse #1) nurses observed during medication administration performed hand hygiene before and after the removal of gloves and 1 of 5 (New Employee #1) newly hired employees was free of communicable diseases. The findings included: 1. Review of the facility's infection control manual documented, "...Section 702... HANDWASHING... PROCEDURE Wash hands... before and after removal of gloves..." Observation of administration of medication via an enteral tube on D hall on 12/9/14 at 5:42 PM, revealed Nurse #1 spilled water from a syringe onto Resident #112's abdomen and onto the nurse's gloves while checking placement of the enteral tube. Nurse #1 moved to the foot of the bed, removed and discarded the wet gloves into the garbage can, put on new gloves and continued the medication administration. Nurse #1 did not wash her hands or use an alcohol based hand gel between changing gloves. During an interview at the medication cart on D hall on 12/9/14 at 5:50 PM, Nurse #1 verified she did not wash her hands when she changed gloves. 2. Review of the facility's infection control manual documented, "...Section 402... PURPOSE... An annual health screen is completed, reviewed, and filed annually in the partner health record..." Review of the personnel record for New Employee #1 did not contain a completed health screen that had been reviewed and signed by a physician indicating that she was free of communicable diseases. During an interview in the business office on 12/10/14 at 3:55 PM, the Assistant Director of Nursing (ADON) was asked if she had proof that New Employee #1 with a hire date of 8/11/14 was free of communicable diseases. The ADON stated, "I can't. I don't know why she was missed."

Based on review of the fall prevention program, contract review, review of a Material Safety Data Sheet (MSDS), review of a manufacturer's website, policy review, medical record review, observation and interview, it was determined the facility failed to be administered in a manner to ensure the environment was safe and free of accident hazards, failed to ensure each resident received complete and accurate assessments and failed to implement appropriate and measurable interventions to prevent potential injuries for 2 of 6 (Residents #161 and 146) residents with falls. The administrator failed to ensure the staff accurately and completely assessed residents with falls, implemented appropriate interventions and provided supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy (IJ). The administrator failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents reviewed with injuries. The administrator failed to ensure proper infection control practices were followed to prevent the potential spread of infections in the terminal cleaning of 50 of 50 resident rooms. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ. This IJ was removed on 7/12/13. The findings included: 1. The Administrator failed to ensure the environment was safe and free of accident hazards, residents received complete and accurate assessments and implemented appropriate and measurable interventions to prevent serious injuries from falls for 2 of 6 (Residents #161 and 146) residents with falls. The facility failed to accurately and completely assess residents with falls, implement appropriate interventions and provide supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy. The facility's failure to consistently follow a systemic process of assessing residents at risk for falls, failure to develop and implement appropriate interventions to prevent falls and injury, failure to develop new approaches to protect residents when current interventions were ineffective and the failure to ensure direct care staff were trained to consistently follow the facility fall prevention program placed Residents #161 and 146 in immediate jeopardy. Refer to F323. The facility was cited with an Immediate Jeopardy (IJ) at F323, F490, F501 and F520 all with a scope and severity of a "J". The facility failed to ensure the environment was safe and free of accident hazards, residents received complete and accurate assessments and implemented appropriate and measurable interventions after each fall to prevent injuries from falls. The facility failed to accurately and completely assess residents with falls, implement appropriate interventions and provide supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy. The IJ was effective 6/4/13 through 7/11/13. An acceptable AOC, which removed the immediacy of the jeopardy, was received on 7/12/13 and actions were validated onsite by the survey team on 7/12/13. An allegation of compliance (AOC) was received on 7/11/13 and documented, "As this plan is being developed, partner (staff member) has been assigned to sit with patient (Resident #161)... until potential implementation of plan in place... Patient will be asked for need to void every 2 hours while awake and given... assistance with regard to all transfers by CNA's (certified nursing assistants) and licensed nurses. While asleep, CNA or licensed nurse staff will round every 1 hour to ensure that the following fall interventions are in place: fall mat on both sides of the bed, bed pan alarm in place, prime snap attached to alarm, urinal within reach and sight. If patient is awake during hourly rounds, patient will be asked for need to void at that time by licensed nurse or CNA. Alarm will be monitored every 12 hours to ensure in working order by licensed nurse... All 1 and 2 hour checks will be logged onto form to measure compliance. Night shift... will be immediately in-serviced with regard to fall interventions and then all other partners (staff) by 7/12/13. DON (Director of Nursing) will monitor daily until substantial compliance is achieved. On 7/12/13 the Administrator presented additional information for the AOC as followed "7/12/13... in-service training began for licensed nursing staff and CNA's on 7/12/13 of the center's policies related to falls risk prevention. Specific attention was given to the expectation that interventions are put in immediately... any partners on leave or otherwise unavailable will be in-serviced prior to their next shift worked... Beginning 7/12/13... 5 licensed nurses and 5 CNAs will be interviewed weekly x (times) 6 weeks for their understanding of the need to put falls risk interventions in place immediately and their role in monitoring the fall interventions..." The surveyors verified the AOC was in place by the following: a. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 was in bed with the bed in low position, fall mats were in place on both sides of the bed, 1/2 side rails were up times 2, bed pad alarm and prime snap alarm were in place, call light was within reach and a staff member at bedside. Observations in Resident #146's room on 7/12/13 at 4:10 PM, revealed fall mats were in place on both sides of the bed. Observations in the front lobby on 7/12/13 at 4:12 PM, revealed Resident #146 had on appropriate footwear sitting on the settee with prime snap alarm and sensor pad alarm attached and urinal within reach and sight. Restorative Nurse beside Resident #146 adjusting the wheelchair. b. On 7/12/13 the surveyors reviewed the inservices of all the staff that were working. No staff will begin work until inserviced. The monitoring forms were reviewed with documented compliance with the 1 hour, 2 hour and 12 hour checks. Non-compliance of the IJ continues at a scope and severity of a "D" level for F490 for monitoring of corrective actions. The facility is required to submit a plan of correction for all tags. 2. The Administrator failed to ensure the Quality Assurance Committee established a method to identify an ineffective fall prevention program. Refer to F520. 3. The Administrator failed to ensure the abuse prevention policy and procedure was implemented to ensure a complete and thorough investigation was completed for an injury of unknown origin or report the incident to the state survey certification agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries. Refer to F225 and F226. 4. The Administrator failed to ensure the facility had an effective infection control program that prevented the potential spread of infections in the facility by failing to ensure the correct method of terminal cleaning was performed. Refer to F441.

Based on contract review, review of the fall prevention program, policy review, medical record review, observation and interview, it was determined the facility failed to ensure the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns, failed to coordinate the medical care and provide clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for residents residing in the facility. The Medical Director failed to ensure the staff accurately and completely assessed residents with falls, implemented appropriate measurable interventions to prevent potential serious injuries for 3 of 6 (Residents #161, 146 and 66) residents with falls or injury of an unknown origin. This placed Resident #161 and Resident #146 in immediate jeopardy (IJ). The Medical Director failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ. This IJ was removed on 7/12/13. The findings included: 1. Review of the Medical Director's contract dated 4/19/12 documented, "...3.3 Physician shall be responsible and accountable for the coordination of medical care of all residents in the Center. Physician shall help the Center obtain and maintain timely and appropriate medical care that supports the healthcare needs of the patients, is consistent with current standards of practice and helps the Center meet its regulatory requirements. Physician shall address issues related to the coordination of medical care identified through the Center's Quality Improvement Committee and program and other activities related to the coordination of care..." 2. The Medical Director failed to ensure the environment was safe and free of accident hazards, residents received complete and accurate assessments and implemented appropriate and measurable interventions to prevent falls and injuries of unknown origin for 3 of 6 (Residents #161, 146 and 66) residents with falls or injury of unknown origin. The Medical Director failed to ensure the staff accurately and completely assessed residents with falls, implemented appropriate and measurable interventions which placed Resident #161 and Resident #146 in immediate jeopardy (IJ). The facility's failure to consistently follow a systemic process of assessing residents at risk for falls, failure to develop and implement appropriate interventions to prevent falls and injury, failure to develop new approaches to protect residents when current interventions were ineffective and the failure to ensure direct care staff were trained to consistently follow the facility fall prevention program placed Residents #161 and 146 in immediate jeopardy. Refer to F323. The IJ was effective 6/4/13 through 7/11/13. An acceptable AOC, which removed the immediacy of the jeopardy, was received on 7/12/13 and actions were validated onsite by the survey team on 7/12/13. An allegation of compliance (AOC) was received on 7/11/13 and documented, "As this plan is being developed, partner (staff member) has been assigned to sit with patient (Resident #161)... until potential implementation of plan in place... Patient will be asked for need to void every 2 hours while awake and given... assistance with regard to all transfers by CNA's (certified nursing assistants) and licensed nurses. While asleep, CNA or licensed nurse staff will round every 1 hour to ensure that the following fall interventions are in place: fall mat on both sides of the bed, bed pan alarm in place, prime snap attached to alarm, urinal within reach and sight. If patient is awake during hourly rounds, patient will be asked for need to void at that time by licensed nurse or CNA. Alarm will be monitored every 12 hours to ensure in working order by licensed nurse... All 1 and 2 hour checks will be logged onto form to measure compliance. Night shift... will be immediately in-serviced with regard to fall interventions and then all other partners (staff) by 7/12/13. DON (Director of Nursing) will monitor daily until substantial compliance is achieved. On 7/12/13 the Administrator presented additional information for the AOC as followed "7/12/13... in-service training began for licensed nursing staff and CNA's on 7/12/13 of the center's policies related to falls risk prevention. Specific attention was given to the expectation that interventions are put in immediately... any partners on leave or otherwise unavailable will be in-serviced prior to their next shift worked... Beginning 7/12/13... 5 licensed nurses and 5 CNAs will be interviewed weekly x (times) 6 weeks for their understanding of the need to put falls risk interventions in place immediately and their role in monitoring the fall interventions..." The surveyors verified the AOC was in place by the following: a. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 was in bed with the bed in low position, fall mats were in place on both sides of the bed, 1/2 side rails were up times 2, bed pad alarm and prime snap alarm were in place, call light was within reach and a staff member at bedside. Observations in Resident #146's room on 7/12/13 at 4:10 PM, revealed fall mats were in place on both sides of the bed. Observations in the front lobby on 7/12/13 at 4:12 PM, revealed Resident #146 had on appropriate footwear sitting on the settee with prime snap alarm and sensor pad alarm attached and urinal within reach and sight. Restorative Nurse beside Resident #146 adjusting the wheelchair. b. On 7/12/13 the surveyors reviewed the inservices of all the staff that were working. No staff will begin work until inserviced. The monitoring forms were reviewed with documented compliance with the 1 hour, 2 hour and 12 hour checks. Non-compliance of the IJ continues at a scope and severity of a "D" level for F501 for monitoring of corrective actions. The facility is required to submit a plan of correction for all tags. 3. The Medical Director failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries. Refer to F225 and F226. 4. During an interview in the conference room on 7/9/13 at 5:23 PM, the Medical Director stated, "...falls are obviously important... physicians have Quality Assurance one monthly with DON, ADON (Assistant Director of Nursing), PT (Physical Therapy) and Administrator... a 2 part meeting first is monitoring issues and review... second utilization of what needs to be done..." During an interview in the medical records office on 7/12/13 at 10:30 AM, the Health Information Manager (HIM) stated, "...the QAA (Quality Assurance and Assessment) committee meets once a month and members are HIM, administrator, DON, ADON, Social Services, Rehab and Medical Director... chart audits done monthly and admission reviews are done within 72 hrs of admission... once the action plan is in place we adapt adopt or abandon which is discussed in the meetings... at present action plans in place we are always working on... weights, infection control, falls, customer satisfaction, incidents and accidents we work on continuously... tracking and trending for falls shows chart that breaks down into shifts, times and location... put interventions in place, report back if it worked or if we need to add or change interventions..." The facility was unable to provide any documentation for an action plan developed on falls. Refer to F520.

Based on review of the fall prevention program, review of the Material Safety Data Sheet (MSDS), review of a manufacturer's website, policy review, medical record review, observation and interview, it was determined the facility's Quality Assurance and Assessment (QAA) committee failed to identify and address quality of care issues such as failure to ensure appropriate and measurable interventions were developed to manage and prevent potential serious injuries for 2 of 6 (Resident #161 and 146) residents of the 31 sampled residents included in the stage 2 review. The failure of the QAA committee to ensure appropriate and measurable interventions were developed placed Resident #161 and 146 in Immediate Jeopardy (IJ) as evidenced by actual serious injury to Resident #161 and potential serious injury to Resident #146. The QAA committee failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents reviewed with injuries. The QAA committee failed to ensure proper infection control practices were followed to prevent the potential spread of infections in the terminal cleaning of the 50 of 50 rooms. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ). This IJ was removed on 7/12/13. The findings included: 1. During an interview in the medical records office on 7/12/13 at 10:30 AM, the Health Information Manager (HIM) was asked if the facility had a QAA committee. The HIM stated, "Yes, we meet once a month. The members are HIM, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Rehabilitation and the Medical Director." The HIM was then asked how they identify issues. The HIM stated, "We do chart audits monthly and admission reviews..." The HIM was asked how they respond to identified issues. The HIM stated, "We do an action plan..." When asked for an action plan for falls, the HIM was unable to provide an action plan for falls. The facility's failure to consistently follow a systemic process of assessing residents at risk for falls, failure to develop and implement appropriate interventions to prevent falls and injury, failure to develop new approaches to protect residents when current interventions were ineffective and the failure to ensure direct care staff were trained to consistently follow the facility fall prevention program placed Residents #161 and 146 in immediate jeopardy. Refer to F323. The IJ was effective 6/4/13 through 7/11/13. An acceptable AOC, which removed the immediacy of the jeopardy, was received on 7/12/13 and actions were validated onsite by the survey team on 7/12/13. An allegation of compliance (AOC) was received on 7/11/13 and documented, "As this plan is being developed, partner (staff member) has been assigned to sit with patient (Resident #161)... until potential implementation of plan in place... Patient will be asked for need to void every 2 hours while awake and given... assistance with regard to all transfers by CNA's (certified nursing assistants) and licensed nurses. While asleep, CNA or licensed nurse staff will round every 1 hour to ensure that the following fall interventions are in place: fall mat on both sides of the bed, bed pan alarm in place, prime snap attached to alarm, urinal within reach and sight. If patient is awake during hourly rounds, patient will be asked for need to void at that time by licensed nurse or CNA. Alarm will be monitored every 12 hours to ensure in working order by licensed nurse... All 1 and 2 hour checks will be logged onto form to measure compliance. Night shift... will be immediately in-serviced with regard to fall interventions and then all other partners by 7/12/13. DON (Director of Nursing) will monitor daily until substantial compliance is achieved. On 7/12/13 the Administrator presented additional information for the AOC as followed "7/12/13... in-service training began for licensed nursing staff and CNA's on 7/12/13 of the center's policies related to falls risk prevention. Specific attention was given to the expectation that interventions are put in immediately... any partners on leave or otherwise unavailable will be in-serviced prior to their next shift worked... Beginning 7/12/13... 5 licensed nurses and 5 CNAs will be interviewed weekly x (times) 6 weeks for their understanding of the need to put falls risk interventions in place immediately and their role in monitoring the fall interventions..." The surveyors verified the AOC was in place by the following: a. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 was in bed with the bed in low position, fall mats were in place on both sides of the bed, 1/2 side rails were up times 2, bed pad alarm and prime snap alarm were in place, call light was within reach and a staff member at bedside. Observations in Resident #146's room on 7/12/13 at 4:10 PM, revealed fall mats were in place on both sides of the bed. Observations in the front lobby on 7/12/13 at 4:12 PM, revealed Resident #146 had on appropriate footwear sitting on the settee with prime snap alarm and sensor pad alarm attached and urinal within reach and sight. Restorative Nurse beside Resident #146 adjusting the wheelchair. b. On 7/12/13 the surveyors reviewed the inservices of all the staff that were working. No staff will begin work until inserviced. The monitoring forms were reviewed with documented compliance with the 1 hour, 2 hour and 12 hour checks. Non-compliance of the IJ continues at a scope and severity of a "D" level for F520 for monitoring of corrective actions. The facility is required to submit a plan of correction for all tags. 2. The QAA Committee failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents reviewed with injuries. Refer to F225 and F226. 3. The The QAA Committee failed to ensure proper infection control practices were followed to prevent the potential spread of infections as evidenced by the method for terminal cleaning for 50 of 50 rooms. Two residents with [MEDICAL CONDITIONS] were observed in isolation rooms. One resident resided on A hall and one resident resided on B hall. Refer to F441.

Based on review of the fall prevention program, medical record review, observation and interview, it was determined the facility failed to ensure the environment was safe and free of accident hazards, failed to ensure assessment of each resident was complete and accurate and failed to implement appropriate and measurable interventions to prevent potential injuries for 3 of 6 (Residents #161, 146 and 66) residents with falls or injury of unknown origin of the 31 residents included in the stage 2 review. The facility failed to accurately and completely assess residents with falls, implement appropriate interventions and provide supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ). This IJ was removed on 7/12/13. The findings included: 1. Review of the facility's fall prevention program documented, "...Falls can have serious consequences for both the resident and the facility... Injuries caused by falls increase the resident's risk of death, decrease the resident's ability to function, and reduce quality of life. Even falls that do not cause injuries lead to fear of falling, which may cause the resident to become less active. In turn, this inactivity hastens the decline of frail residents... Poor safety practices also increase fall risk... These include... unsafe transfer and mobility... The program goal was to reduce falls in nursing homes... Step 5 is to identify those residents at high risk of falling who will be included in the program... Step 6 is to conduct the program assessments for high-risk residents. These assessments are designed to identify problems and guide you to solutions... Unsafe behavior. Some residents fall because of unsafe behavior related to dementia... To manage residents with unsafe behavior, it is important to learn about the behavior pattern... know what triggers the behavior... Prescribed drugs should be reviewed... The resident's medical status should be evaluated... for medical condition may be contributing to the behavioral symptoms. Each resident should also be assessed to determine what specific strategies would reduce fall risk... The safety and appropriateness of all equipment and restraint, including alarms, barriers, siderails and seating items should be reevaluated... The Fall Prevention Nurse will use Section 1 of the High-Risk Resident Selection Form to decide whether or not to enroll the resident in the program... There are four possible assessments from which to choose of each high-risk resident in the program... They are the Walking Assessment, Wheelchair Assessment, Benzodiazepine Assessment, and Behavior Assessment... For unsafe behavior, check if the resident had any of the following unsafe behaviors two or more times in the past month: a. Tried to stand, transfer, or walk alone unsafely; b. climbed over bed rails or tried to get out of the bed alone unsafely; c. Walked or paced when too tired to be safe or d. Propelled a wheelchair or walked alone in unsafe areas such as outdoors on rough pavement or in a parking lot... The Behavior Assessment will help you manage unsafe behaviors that often increase fall risk... First, you are asked to describe the unsafe behavior in as much detail as possible, including time of day, location, frequency, equipment present and what appears to precipitate the behavior... Second, you will need to read the chart and talk with staff to determine what the current behavior management plan is and whether it is effective. You are asked to record the approaches and their effectiveness. Third, you are asked to look at a list of suggestions and to check each task you think may improve the resident's safety. These tasks, as well as any current approaches which are effective, will be added to the resident's care plan... When the assessments for a high-risk resident are finished, the Fall Prevention Nurse must ensure that the tasks that were identified to improve the resident's safety are carried out in an organized way... 1. Review the assessments. 2. Write the nursing tasks on the Action List of the High-Risk Resident Follow-Up Form and review the list with staff. 3. Follow-up with unit staff to ensure that tasks on the Action List are being carried out and revise them as necessary. 4. Inform other staff of their tasks, complete your tasks, and follow-up to ensure that all tasks are completed 5. Review resident falls using the Fall Record of the High-Risk Resident Follow-up Form and revise the Action List as necessary..." 2. Medical record review for Resident #161 documented an admission date of [DATE] with [DIAGNOSES REDACTED]., Osteoarthritis, Dysphagia, Gastro Esophageal Reflux Disease and History od Clostridium Difficile (C-diff). The admission Minimum Data Set ((MDS) dated [DATE] documented the resident with a brief interview memory status (BIMS) of moderate impaired cognition, requiring extensive assistance with Activities of Daily Living, at risk for falls and receiving antidepressants and antibiotics. The high risk patient selection form (facility fall risk assessment) dated 5/28/13 documented assessment type as "admission... resident had a fall in past 30 days... had taken antidepressant Remeron in past 7 days... and proceed with section 2..." Section 2 of the high risk patient selection form dated 6/17/13 documented, "All patients in the program will need a transfer and mobility assessment, unless they are always assisted or bed bound... "always asst (assist)" care plan decision to proceed" and "DX (diagnosis): L (left) Hip Fx (fracture) R/T (related to) Fall dx Alzheimer's dementia..." There was no documentation on the unsafe behavior area of the assessment form. There was no behavior assessment completed per the facility's fall prevention program. A restorative nursing screening form dated "6/17/13 late entry for 6/1/13" documented "...requires ext (extensive) asst (assistance) x (times) 2 w (with) / toileting needs- 2 (secondary to) L Hip Fx- Bed mobility ext asst x 2, transfers ext asst x 2, ambulation w/RW (rolling walker) min (minimum) - max (maximum) asst 1- (to) 2 in corridor & (and) room... (Initiate Fall program-High Risk)." The interim plan of care dated 5/28/13 documented, "Identified Problems / Needs of... assess for unsteady gait, dizziness & intervene as needed, verbally remind patient not to ambulate alone, Fall Risk Assessment, Low bed..." The admission MDS dated [DATE] documented the resident with a BIMS of moderate impaired cognition. This is not an appropriate intervention for a cognitively impaired resident. The interim plan of care was updated on 6/3/13 and documented, "Personal alarms as needed Prime Snap (name of a personal body alarm) 6/3." The interim plan of care was updated on 6/4/13 and documented, "Fall 6/4/13-6/4 Monitor & Assist frequently r/t (related to) diarrhea." The comprehensive care plan dated 6/17/13 documented, "...(Resident #161's name) requires assistance with adls (activities of daily living) with the approach of "Bed mobility, transfers, and ambulation with asst. of staff as requires asst. per staff for in room BRP (bathroom privileges) qd (every day)..." The facility failed to follow the comprehensive care plan for assistance with toileting. The certified nursing assistant (CNA) care card documented, "...Ambulation/ Transferring/ bed mobility assistance x 2... Fall Risk hip precautions..." A post falls nursing assessment dated [DATE] at 4:30 PM documented, "Pt (patient) was found in (on) the floor after having an incontinent episode... safety device in use Alarm... Description of injury Abrasion to Right Elbow... What immediate interventions were initiated to prevent future falls?" The facility staff documented, "...Patient was assisted with toileting and frequently monitored due to diarrhea." A falls meeting agenda dated 6/5/13 documented, "...(listed room number) - 6/4- 4:30pm- found on floor Pt had incontinent episode and slipped, Alarm sounding. Moved closer to NSG (nursing) station 6-5-13 Now in (listed a different room)." There was no documentation of a post falls investigation or a high risk resident follow-up form provided by the facility for this fall. There was no documentation of the "always asst" intervention documented on the admission high risk patient selection form. The resident sustained [REDACTED]. A post falls nursing assessment dated [DATE] at 11:20 AM documented, "CNA heard patient (Resident #161) call out. She (CNA) went to room and found patient lying on floor inside bedroom entrance door with bathroom door up against outer door... exiting commode while unattended... patient stated got up from toilet and lost my balance... safety devices in use low bed alarm... description of injury... Site 1 Patient c/o (complained of) severe right hip pain external left leg rotation... site 2 knot w/redness top of head... what immediate interventions were initiated to prevent future falls?" The staff documented, "...attend while toileting..." The post falls investigation dated 6/26/13 documented, "...Fall investigation 6/22/13 11:20 AM type of injury bone fracture hip hematoma head... exiting commode while unattended... needed care plan changes: Do not leave alone in bathroom..." A nurse's note dated 6/22/13 at 2:50 PM documented, "Pt. admitted to (name of local hospital)... to have surgery." A nurses note dated 6/25/13 at 8:10 PM documented, "...Pt. arrived via ambulance stretcher... Dsg (dressing) to R (right) hip C/D/I (clean dry intact)..." There was no documentation of the "always asst" documented on the admission high risk patient selection form. There was no documentation of the frequent monitoring and assisted with toileting intervention implemented from previous fall. There was no high risk resident follow-up form completed by the facility per fall prevention program. Resident #161's 6/22/13 fall resulted in a fractured right hip injury and a hematoma to the head. A post falls nursing assessment dated [DATE] at 9:45 PM documented, "Found patient on the floor beside bed in front of bathroom ambulating in room unattended pt. stated he was just going to sit down and his legs gave out and he fell to the floor... safety devices in use: low bed, alarm, fall mat... what immediate interventions were initiated to prevent future falls? The staff documented, "evaluate & assess need for prompt & assist toileting program..." A post falls investigation dated 7/9/13 documented, "...Fall investigation 7/5/13 9:45 PM type of injury Abrasion Rib." There was no high risk resident follow-up form completed per the facility's fall prevention program. There was no documentation of frequent monitoring or "always asst" being provided. Resident #161's 7/5/13 fall resulted in an abrasion to the rib area. During an interview in the conference room on 7/10/13 at 5:00 PM, the Assistant Director of Nursing (ADON) was asked what was the process the nurses are to do for a fall. The ADON stated, "When a resident falls the nurses complete a post falls assessment. They document what happened and they also document the immediate intervention started to prevent future falls. This is put in the computer and then I (ADON) do a post falls investigation... On the first fall he (Resident #161) got up and fell was having diarrhea, and nurses put in place assist with toileting and frequent monitoring due to diarrhea." The ADON was asked to define frequent monitoring. The ADON stated, "More often than routine which is every 2 hours." The ADON was asked where this frequent monitoring was documented. The ADON stated, "Not documented except in nurses notes. On the second fall the nurses put in place to attend while toileting. Yes, he was left unattended and he was not suppose to be. On the 3rd fall nurses put in place prompt and assist toileting." The ADON was asked what the difference between frequent monitoring and prompt and assist toileting was. The ADON stated, "The prompt and assist is documented by the restorative aide and the resident is assessed. He is not yet on the program we are still assessing." The ADON was asked if frequent monitoring was an appropriate intervention. The ADON stated, "No." The ADON was asked if frequent monitoring was measurable. The ADON stated, "It is not." During an interview on the B hall on 7/10/13 at 6:15 PM, when asked how CNA's find out about residents at risk for falls, CNA #3 stated, "The nurses tell us who is at risk for falls." During an interview at the AB nurses' station on 7/10/13 at 6:25 PM, Licensed Practical Nurse (LPN) #2 was asked what procedure is used to assess residents for fall risk? LPN #2 stated, "The admitting nurse completes the high risk fall assessment and follows the care path. If it triggers then we put in preventative interventions and send the form to restorative. Interventions include tab alarms, low bed, mats... We do not use falling star (name of a fall prevention program) anymore." During an interview in the conference room on 7/10/13 at 7:00 PM, the Director of Nursing (DON) was asked what procedure is used to assess residents for fall risk? The DON stated, "We do not use falling star anymore. We have updated forms and the nurses are using the most current forms." The DON was asked why all assessments were not done per the Fall Prevention Program? The DON stated, "(Named Resident #161) did not get walking / wheelchair assessments because he was an "always gets assistance." During an interview in the conference room on 7/11/13 at 9:20 AM, CNA #4 was asked how they know what care to provide to a fall risk resident. CNA #4 stated, "For resident with behaviors... we have daily assignments. We get report from the nurses and we use the care cards... We know if they (residents) have a fall alarm on and a fall pad. They (residents) are a fall risk if they have those and just the fall risk residents have those..." CNA #4 was asked about care provided for Resident #161. CNA #4 stated, "We do frequent checks, routine is 1 to (-) 2 hours. For him (Resident #161) we check every 30-40 minutes... On the day (Resident #161) fell he had taken himself to the bathroom, he told us that..." During an interview in the conference room on 7/11/13 at 10:30 AM, the Registered Physical Therapist (RPT) was asked the cognitive and physical mobility status of Resident #161. The RPT stated, "(Named other RPT) and I take turns taking care of (Resident #161)." The RPT was asked what was Resident #161's cognitive status on admission. The RPT stated, "On admission he had dementia, confusion, physically he ambulated with front wheel walker, had 3/5 (3 is resident's actual score 5 being highest score of being independent) right weakness, 2/5 left weakness, physical mobility scale of 12/45 (45 indicating independently stable) did not ambulate on eval (evaluation) due to cognition, by 6/12/13 he had improved to 20/45, did walk with minimal assist x (times) 1 with FWW (front wheel walker) for 50 ft (feet) with 25% (percent) verbal cueing. On 6/18/13 he walked 75 ft. with rest breaks with contact guard to minimal assist with 25% verbal cueing was scored 24/45 transfers bed - wheelchair with minimal assist and minimal assist sit to stand. On 6/26/13 Occupational Therapist (OT) documented he was able to follow 1 step commands. OT on 5/29/13 documented he was alert to person with increased instruction time/cueing. OT documented on 6/18/13 education with patient regarding safety with toileting. On 7/2/13 OT documented educated on safety with wheelchair with fair understanding due to confusion and 1- (on) 1 with slow pace..." An interview was conducted in the conference room on 7/11/13 beginning at 5:40 PM with the fall team members as follows: Unit Manager (UM), Social Worker (SW), Registered Physical Therapist (RPT), DON, and Falls Prevention Nurse/ADON. The falls team was asked to describe the process staff follow from admission forward concerning residents at risk for falls and having falls? The DON stated, "Nurses assess and decide preventions, before the resident is even admitted using the referral information. If a resident has had a hip fracture we will put a prime snap (a personal body alarm) in the room." The DON was asked what training do the nurses receive to be able to determined what interventions are needed? The DON stated, "We train our nurses. We use a mentor program." The fall prevention committee members were asked what information is used to train nurses? The fall prevention team gave no answer. The facility was unable to provide a training protocol used to train the staff. The fall prevention committee members were asked to explain how risks and interventions were decided based on the assessment form being used? The UM stated, "Nurses do top part (high risk patient selection form), bottom part goes to restorative nurse. We make decisions based on our education and communication..." The ADON stated, "Nurses screen residents to see if restorative needs to complete the restorative assessment part." The UM stated, "Restorative nurse talks with UM. We discuss interventions." The fall committee team was unable to explain how risks and interventions were decided. The fall prevention committee members were asked what does "always assist" mean? The UM stated, "We assist patient in room, physical assist- yes." The ADON stated, "Always means always needs assistance." The RPT stated, "I would have to assess, is it minimal, maximum, contact. Would do assessment and get physician order. Would do a time up and go test assessment." The DON stated, "Always means needs assistance all the time, with adls, mobility, always, every time." The fall prevention committee team was unable to consistently describe the meaning of "always assist." The fall prevention committee members were asked how "always assist" was done and documented? The DON stated, "Make rounds every 2 hours and provide what assistance needed. If resident is confused, we keep them out of room, use dementia kit, memory care, keep engaged. If the resident is in isolation for[DIAGNOSES REDACTED], I expect them to make rounds and take to the bathroom. I am having a problem being stuck on the word always... It is not okay for them (residents) to go to the bathroom, transfer, ambulate by themselves. They (staff) know who by nurses report, communication, staff would know. I expect them (staff) to check and toilet." The UM stated, "The prime snap and bed alarms help us know when to go assist the resident." The ADON stated, "Alarms do not stop falls they just alert us." The UM stated, "Prime snap and alarms help us anticipate resident needs." The fall prevention team was unable to consistently describe how "always assist" was implemented. They were unable to provide any documentation of the "always assist." They failed to recognize that when an alarm sounds it is too late for staff to anticipate the residents needs. The fall prevention committee members were asked what is done about residents who remove the alarms? The DON stated, "If snaps are taken off then we put the bed alarm or wheelchair pad alarms or move the alarm to a place where they (resident) cannot reach the alarm." The fall prevention committee members were asked, what is an intervention? The DON stated, "Something in place to make sure that it (falls) doesn't happen again." The fall prevention committee members were asked if they felt they had done everything possible to keep Resident #161 safe from falls? The ADON stated, "We have done everything we can... Frequently means more often than every 2 hours routine. On his first fall he had had a bowel movement. The frequent monitoring was what the staff put in place immediately..." The fall prevention committee was unable to consistently describe the interventions that had been put in place for this resident. There was no documentation of the interventions being implemented. The fall prevention committee members were asked about implementation of the new forms. The ADON stated, "We changed forms. We recognized a need trying to get more information..." The fall prevention committee was unable to provide evidence that the falls had been investigated to determine the root cause. The fall prevention committee members were asked if the fall prevention program information had been read? The ADON stated, "No, I have not read the fall program. On his second fall he (Resident #161) had taken himself to the bathroom. The alarm did not sound, had malfunctioned, the prompt/toileting intervention is still being assessed." The fall prevention committee failed to consistently and thoroughly investigate the falls to determine the root cause. There was no documentation that the malfunctioned alarm had been addressed. The fall prevention committee failed to read and consistently implement the fall prevention program the facility was using. The fall prevention committee members were asked, what intervention was put in place after the last fall to keep Resident #161 safe while the prompt/toileting assessment is being done? No answer was received from any of the fall prevention committee members. Observations in Resident #161's room on 7/8/13 at 5:30 PM, revealed Resident #161 seated in a chair with one mat on the floor on the bathroom side of the bed. Observations in Resident #161's room on 7/10/13 at 8:10 AM, revealed Resident #161 in a wheelchair with a mat on the floor on the bathroom side of the bed. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 in bed asleep with mats now on both sides of the bed. The resident was currently being monitored by the RPT. Resident #161 sustained three falls with injuries, with one of those falls resulting in a fractured hip. The facility failed to thoroughly and consistently investigate falls to determine the root cause, failed to implement appropriate and measurable interventions addressing falls, and failed to document interventions which resulted in a serious and immediate threat to the health and safety of Resident #161. 3. Medical record review for Resident #146 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] and quarterly assessment dated [DATE] indicating the resident was severely cognitively impaired and falls were checked. The high-risk patient selection form completed on 1/15/13 for admission documented an intervention of "always assist" on the narrative section of the form. Instructions on the form documented, "...For patients who are eligible for the Fall Prevention Program PROCEED WITH SECTION 2 (box checked)... complete the rest of this form..." Section 2 documented, "...Put a check (symbol for checkmark) in the box beside each assessment that applies to the patient... All patients in the program will need a transfer and mobility assessment, unless they are always assisted (circled with ink) or bed bound... Walking Assessment... (no check in box)... Wheelchair Assessment / Seating Assessment... (no check in box)... NARRATIVE documents "always assist..." SECTION 2... BEHAVIOR ASSESSMENT... 1... ANTIPSYCHOTICS... Zyprexia (is circled)... Seroquel (was not marked)... 2... UNSAFE BEHAVIOR (is circled)... (listed under) UNSAFE BEHAVIOR... tried to stand, transfer or walk alone unsafely, the box (is checked)... tried to get out of bed alone unsafely (is circled)... walked or paced when too tired to be safe (is checked)... CARE PLAN DECISION: PROCEED (is checked)... (listed [DIAGNOSES REDACTED]. The behavior assessment antipsychotics assessment was not completed, nor was the behavior assessment unsafe behavior assessment completed per the facility fall prevention program. The resident's initial care plan dated 1/14/13 and the care plan revised on 5/3/13 documented the resident was identified at risk for falls. Fall interventions of the care plan were low bed, fall mats, keep areas free of clutter, prime snap alarm, and non-skid socks. Review of post falls nursing assessments documented the following: a. "...2/28/13... 3:30 AM... Describe the actual known facts: What was seen or heard: CNA WALKED IN ROOM AND PT (patient) WAS ON THE FLOOR IN FRONT OF BED... Describe task patient attempting at time of fall: Ambulating in room unattended... Safety devices in use: LOW BED... Patient was wearing following devices: FOOTWEAR... What immediate interventions were initiated to prevent future falls? Non-skid shoes/socks..." A post falls investigation form for Resident #146 on 2/28/13 documented, "NEEDED CARE PLAN CHANGES: non-skid socks/shoes..." No new intervention had been put into place for this fall. The care plan was not updated with any new intervention for this fall. b. "...3/13/13... 2:50 PM... Describe the actual known facts: What was seen or heard: TEC (technician) AS GIVING SHOWER TEC SAID PT WENT TO fell SHE TRIED TO CATCH PT BUT COULD'NT (could not) PT fell TO FLOOR ON BOTTOM... Patient was wearing following devices: NONE... What immediate interventions were initiated to prevent future falls? Keep walker/assistive device within reach..."A post falls investigation form for 3/13/13 documented, "NEEDED CARE PLAN CHANGES: Non-skid shoes/socks..." No new intervention had been put into place for this fall. Walker and assistive devices is not an appropriate intervention for a fall in the shower. The care plan was not updated with any new intervention for this fall. c. "...3/25/13... 11:15 AM... Describe the actual known facts: What was seen or heard: No answer in space... Safety devices in use: LOW BED, ALARM... Patient was wearing following devices: FOOTWEAR... What immediate interventions were initiated to prevent future falls? Low bed..."A post falls investigation form for 3/25/13 documented, "NEEDED CARE PLAN CHANGES: low bed..." No new intervention had been put into place for this fall. The care plan was not updated with any new intervention for this fall. d. "...3/27/13... 5:45 PM... Describe the actual known facts: What was seen or heard: PT FOUND ON FLOOR SITTING UPRIGHT ON HER BOTTOM FACING THE AIR CONDITIONER... Safety devices in use: LOW BED, ALARM, FALL MAT... Patient was wearing the following devices: NONE... What immediate interventions were initiated to prevent future falls? fall mat..." A post falls investigation form for 3/27/13 documented, "NEEDED CARE PLAN CHANGES: Fall mat..." No new intervention had been put into place for this fall. The care plan was not updated with any new intervention for this fall. e. "...4/13/13... 10:15 PM... Describe the actual known facts: What was seen or heard: CNA ON 10PM ROUNDS ALERTED NURSE THAT PT WAS SITTING ON BOTTOM IN FLOOR BESIDE BED (written in ink was on fall mat)... Safety devices in use: LOW BED, FALL MAT... Patient was wearing the following devices: NONE... What immediate interventions were initiated to prevent future falls? Use socks with non-skid tread..." A post falls investigation form for 4/13/13 documented, "NEEDED CARE PLAN CHANGES: no intervention documented..." No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. f. "...4/20/13... 12:30 PM... Describe the actual known facts: What was seen or heard: TEC FOUND PT ON FALL MAT... Safety devices in use: LOW BED, FALL MAT... Patient was wearing the following devices: GLASSES, FOOTWEAR... What immediate interventions were initiated to prevent future falls? MAKE SURE PT SIT FAR ENOUGH BACK WHEN SITS DOWN..."A post falls investigation form for 4/20/13 documented, "NEEDED CARE PLAN CHANGES: none documented." No new interventions had been put in place for this fall. The suggested intervention on the "immediate" was not carried over to the "post falls investigation form. The form did not list any intervention to be put in place. The care plan was not updated with any new intervention for this fall. g. "...4/23/13... 12:15 am... Describe the actual known facts: What was seen or heard: ALARM SOUNDING ENTERED ROOM TO FIND PT SITTING ON BUTTOCKS BESIDE BED. SMALL CUP OF WATER SPILLED ON THE FLOOR... Safety devices in use: LOW BED, ALARM, FALL MAT... Patient was wearing the following devices: NONE... What immediate interventions were initiated to prevent future falls? Use socks with non-skid tread..."A post falls investigation form for 4/23/13 documented, "NEEDED CARE PLAN CHANGES: none documented... attached is a "Post Falls Assessment"..." No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. h. "...4/25/13... 8:10 PM... Describe the actual known facts: What was seen or heard: NURSE HEARD PT YELLING "HELLO" NURSE ENTERED SHOWER ROOM TO FIND PT SITTING ON BUTTOCKS WITH PANTS OFF AND BM (bowel movement) ON FLOOR... Safety devices in use: LOW BED, ALARM, FALL MAT... Patient was wearing the following devices: footwear, assistive devices (walker)... What immediate interventions were initiated to prevent future falls? Walking Assessment or Wheelchair Assessment..."A post falls investigation form on 4/25/13 documented, "NEEDED CARE PLAN CHANGES: Restorative to eval (evaluate) for prompt & (and) assist toileting Program... alarm not working (checked in box)..." The new intervention of walking assessment or wheelchair assessment was added for this fall, however, there were no documentation addressing the alarm. The walking assessment or wheelchair assessment was not carried over to the "post falls investigation". This intervention was not added to the care plan nor was there any documentation that this intervention had been implemented. i. "...5/4/13... 12:30 PM... Describe the actual known facts: What was seen or heard: PT FOUND SITING (sitting) ON FLOOR BESIDE W/C (wheelchair)... Safety devices in use: question not generated on this form... Patient was wearing the following devices: GLASSES, FOOTWEAR... What immediate interventions were initiated to prevent future falls? Chair alarm..."A post falls investigation form for 5/4/13 documented, "NEEDED CARE PLAN CHANGES: None documented..." No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. j. "...5/13/13... 6:30 PM... Describe the actual known facts: What was seen or heard: PT FALL WAS WITNESSED BY (nurse's name) AND (nurse's name) THIS EVENING, THEY BOTH STATED SHE JUST SLID OUT OF THE WHEEL CHAIR... PT SEEMED TO BE TRYING TO GO TO RESTROOM, ALARMS ARE IN PLACE AND WORKING... Safety devices in use: ALARM... What immediate interventions were initiated to prevent future falls? Chair alarm..." A post falls investigation form for 5/4/13 documented, "NEEDED CARE PLAN CHANGES: None documented..." No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. k. "...6/13/13... 6:30 AM... Describe the actual known facts: What was seen or heard: PT'S ROOMMATE CAME TO NURSES STATION AND STATED THAT PT WAS ON THE FLOOR... Safety d