Every finding on record at NHC Healthcare, Farragut

Based on facility policy review, medical record review, and interview, the facility failed to assess and obtain a physician's order for medication self-administration for 1 resident (Resident #128) of 1 resident reviewed for self-administration of medication. The findings include:Review of the facility's policy titled, Self-Administration of Medications, dated 2/2025, revealed, a physician order should be obtained then an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive .physical, and visual ability to carry out this responsibility .a member of the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis .the results of the interdisciplinary team member's assessment of resident skills .are recorded in the resident's medical record .Review of the medical record revealed Resident #128 was admitted to the facility on [DATE] with diagnoses including Diabetes, Heart Failure, and Lung Disease. Review of a Social Services Progress Note dated 2/3/2026, revealed Resident #128 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the Physician Order Report dated 2/2/2026-2/11/2026, revealed Resident #128 had an order .insulin aspart [fast-acting insulin to regulate elevated blood sugar levels] .for use of insulin pump, and uses 1 vial every 2 days .please send . and an order, .May use Dexcom [type of insulin pump] . There was no Physician's Order for Resident #128 to self-administer the insulin by refilling the insulin pump with the insulin from a vial sent by the pharmacy. Review of the medical record revealed Resident #128 did not have documentation an assessment had been completed for the resident's ability to self-administer medication.During an interview on 2/11/2026 at 9:15 AM, Resident #128 stated he cared for and refilled his insulin pump himself, using insulin the facility pharmacy provided. Resident #128 was knowledgeable on the process of refilling the insulin pump in a safe and appropriate manner. During an interview on 2/11/2025 at 9:55 AM, the Director of Nursing (DON) confirmed an assessment on the ability to self-administer medication and a Physician's Order to self-administer medication had not been obtained by the facility.

Based on the facility policy review, Lippincott Nursing Center website review, medical record review, and interviews, the facility failed to ensure basic nursing standards for the rights of medication administration were followed for 1 resident (Resident #12) of 7 residents reviewed for insulin administration.The findings include:Review of the facility's policy titled, Specific Medication Administration Procedures, dated 2/25/2025, revealed .Review medications for accuracy .Check MAR/TAR [Medication Administration Record/ Treatment Administration Record] for order .Prior to administering medication .check the label [medication label] against the order [Physician's order] on the MAR .Review of the Lippincott Nursing Center Website resource of the Nursing Drug Handbook dated 2025- 2026, revealed .Medication Errors in Nursing .As a final step in the administration process .and the .defense against medication errors .nurses must follow the rights of medication administration .Right Patient .Right medication .Right dose .Right route .Right time .Right Documentation .Right reason .Right response .Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Diabetes, and Diabetic Neuropathy. Review of a comprehensive care plan for Resident #12 dated 8/18/2021, revealed .Diabetes- at risk for adverse effects .due to use of .insulin .Approach .Administer insulin as ordered .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #12 had an active diagnosis of Diabetes and received insulin injections. Review of a Physician's Order Report for Resident #12 dated 11/1/2025 -11/30/2025, revealed the resident was prescribed Humalog Kwikpen insulin (Lispro) (an injectable medication used to rapidly lower blood glucose levels) 200 unit/milliliter (u/ml), to give 3 units subcutaneously before meals (start date 6/19/2025) and Lantus Solostar (Glargine) (an injectable medication used to gradually lower blood glucose levels) 100 u/ml, give 32 units subcutaneously at bedtime (start date 7/17/2025). Review of a nursing progress note for Resident #12 dated 11/7/2025 at 10:50 PM, revealed .[Resident #12] Received Humalog 32 units [the Humalog order was for 3 units] instead of prescribed Lantus 32 units [received at approximately 10:30 PM] .MD [Medical Doctor] notified .Review of a Telehealth Consult visit (a virtual medical visit with a physician) for Resident #12 dated 11/7/2025 at 10:51 PM, revealed .insulin overdose .Received Humalog 32 units instead of prescribed Lantus 32 units approximately 20 minutes prior to encounter [Telehealth visit] .Glucose measured at 197 milligram/deciliter (mg/dl) [approximately 10:30PM], then dropped to 146 mg/dl [at approximately 10:50 PM] after insulin administration .No symptoms reported with current glucose levels .Accidental administration of rapid-acting insulin .in place of long acting insulin .Currently asymptomatic with stable vital signs and blood glucose levels within acceptable range.No immediate need for hospital transfer; will monitor closely in the facility for now .Continue close observation for any symptoms of hypoglycemia .including lightheadedness, dizziness, or altered mental status .Ensure blood glucose remains above 90 mg/dl; if glucose drops below this threshold despite interventions, consider transfer to the emergency department . (normal blood glucose ranges 70-100 mg/dl). Review of a nursing progress note for Resident #12 dated 11/7/2025 at 11:15 PM, revealed .Patient [Resident #12] sent to [Hospital] for evaluation and treatment .no signs of hypoglycemia, however BG [Blood Glucose] 116 [116 mg/dl] [approximately 25 minutes] after glucose gel X [times] 2 [2 doses] given .Patient eating peanut butter crackers and drinking sprite .Review of a comprehensive care plan for Resident #12 revised 11/7/2025, revealed .Diabetes- at risk for adverse effects .due to use of .insulin .Approach .Administer insulin as ordered .send to ER [Emergency Room] for eval [evaluation] of possible impending hypoglycemia .Review of an emergency room (ER) visit note for Resident #12 dated 11/7/2025, revealed .Adm [Admit] Date 11/7/2025 23:37 [11:37 PM] .comes to us [ER] after being given 32 units of Humalog versus Lantus .At this time glucose is 70 Will continue to monitor .he [Resident #12] is p.o. [by mouth] tolerant so he is eating and drinking at this time .he [Resident #12] is asymptomatic .Review of a nurse progress note for Resident #12 dated 11/8/2025 at 7:24 AM, revealed .Patient returned [to the facility] via stretcher/ EMS [Emergency Medical Services] .During an interview on 2/10/2026 at 1:48 PM, Resident #12 stated he had a diagnosis of Diabetes and was prescribed 3 units of fast acting insulin (Humalog/lispro) three times per day and 32 units of long-acting insulin (Lantus) one time per day at bedtime. Resident #12 stated in November 2025 (unable to recall the exact date) the night shift nurse (unable to recall the nurses name) accidentally administered 32 units of the fast-acting insulin instead of the long-acting insulin. Resident #12 stated he remained asymptomatic after the incident but agreed to go to the ER for an evaluation after he was requested to go by the nurse. During a telephone interview on 2/11/2026 at 2:17 PM, Licensed Practical Nurse (LPN) A stated she recalled the insulin medication error on 11/7/2025 which involved Resident #12. LPN A stated at approximately 9:30 PM- 10:30 PM (unable to recall the exact time) she retrieved an Insulin pen, prescribed for Resident #12, from the medication cart and administered 32 units from the Humalog insulin pen (LPN A thought she had retrieved the Lantus insulin pen and retrieved the Humalog pen in error). LPN A stated when she returned to the medication cart, she immediately realized she had administered Humalog 32 units instead of the ordered dose of Lantus. LPN A stated Resident #12 remained asymptomatic and showed no signs of hypoglycemia after the incorrect dosage of insulin was administered or prior to being transported to the ER. LPN A further stated for precautionary measures she requested for Resident #12 to be transferred to the local ER for evaluation. LPN A confirmed she failed to follow the eight rights of medication administration and did not verify the medication label on the insulin pen matched the Physician's order for Resident #12, prior to administering the insulin. During an interview on 2/11/2026 at 2:23 PM, the Medical Director stated he was at the facility 4 days per week, was very familiar with Resident #12, and the insulin error on 11/7/2025. The Medical Director stated had he been the provider on call on 11/7/2025, he would have ordered the necessary treatment in house to treat any hypoglycemic episodes to prevent the ER visit. The Medical Director stated he agreed with the transfer of Resident #12 to the ER as recommended by the Telehealth Consult and LPN A, for precautionary measures. The Medical Director stated the LPN's prompt identification and quick response to the insulin administration error prevented any harm or adverse effects to Resident #12. During an interview on 2/11/2026 5:11 PM, The Director of Nursing (DON) stated she recalled the insulin medication error on 11/7/2025 with Resident #12. The DON confirmed LPN A failed to follow the eight rights of medication administration and did not verify the medication label on the insulin pen matched the Physician's order prior to administering the insulin to Resident #12 which resulted in the medication error.

Based on facility policy review, observation, and interview, the facility failed to maintain a sanitary kitchen environment by failing to properly store opened food items that were observed in 1 of 1 dry storage room and 1 of 1 reach in freezer with the potential to affect 89 of 91 residents. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, showed .REFRIGERATOR AND FREEZER STORAGE .Foods will be stored .Clearly labeled with the contents and the use by date .DRY STORAGE .if opened .should be clearly labeled . During a tour of the kitchen on 9/11/2023 at 10:47 AM, with the Dietary Manager and the Regional Dietician, the following items were found. In the dry storage: 1- 3.9 liter bottle of olive oil, 1/8 full, opened, and unlabeled 1- 16-ounce jar of low sodium chicken base, full, opened, and unlabeled In the reach-in freezer: 1- 5 pound bag sweet potato fries, 1/2 full, opened, and unlabeled During an interview on 9/11/2023 at 11:03 AM, the Dietary Manager confirmed the olive oil, chicken base and sweet potato fries were stored incorrectly and available for resident use.

Based on medical record review, observation, and interview, the facility failed to maintain an accurate medical record for 1 Resident (#6) of 19 residents reviewed. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Long Term Current Use of Insulin, Hypertension, Dementia, and Major Depressive Disorder. Review of Resident #6's physicians orders dated 8/17/2023, showed fasting blood sugar before meals and at bedtime and contact the provider (Physician or Nurse Practitioner) for blood sugar less than 70 and greater than 400. Review of the medication administration record (MAR) for [DATE] showed an entry on 8/18/2023, .Blood Sugar .424 .called [Nurse Practitioner] .and order received to give 12 units lispro insulin .and retest in 2 hr [hour] . Continued review showed no documentation the 12 units of insulin had been administered or the retest of the blood sugar (BS) had been documented on the MAR. During an interview on 9/13/2023 at 4:43 PM, the Director of Nursing (DON) stated she had contacted Registered Nurse #1, the RN had administered 12 units of insulin to Resident #6, rechecked the BS 2 hours later as ordered, and the BS was within normal range. During an interview on 9/13/2023 at 4:55 PM, the DON confirmed the facility failed to maintain an accurate medical record related to insulin administration and rechecks of a BS level for Resident #6.

Based on review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 1 of 4 Nurse Aides (NA) #1 was removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant (CNA) after 120 days of taking the NAT program. The findings include: Review of the facility's working schedule for the months of 8/2023 and 9/2023 showed NA #1 had worked as a NA and performed direct resident care. During an interview on 9/12/2023 at 10:22 AM, NA #1 stated he had worked at the facility for 5 months, continued to provide direct resident care, and took the certification test on 9/12/2023. During an interview on 9/13/2023 at 7:48 AM, the NAT Instructor stated NA #1 had taken the NA certification examination on 9/12/2023 and had passed. The NAT Instructor stated NA #1 had worked at the facility providing direct resident care since 4/3/2023. During an interview on 9/13/2023 at 8:25 AM, the Registered Nurse Unit Manager stated NA #1 had worked on the floor as an NA. Review of NA #1's employee file showed he was hired on 4/3/2023 and is currently employed as a NA. During an interview on 9/13/2023 at 8:15 AM, the Administrator confirmed NA #1 had completed the NAT class at the facility, had worked on the floor as an NA, and had tested on [DATE] for the NA certification. The Administrator confirmed NA #1 had not tested within the 120 day time frame of completing the NAT program.

Based on facility policy review, observation and interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, for 1 resident (Resident #40) of 3 residents reviewed for wound care. The findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Long Term (current) Use of Anticoagulants, Other Giant Cell Arteritis, Long Term (current) Use of Systemic Steroids, Peripheral Vascular Disease, and Acquired Absence of Other Right Toes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Further review showed Resident # 40 had a pressure reducing device on the chair and bed and the resident had venous and arterial ulcers. Review of Resident #40's comprehensive care plan dated [DATE], showed .Right lower extremity wounds cleanse right lateral foot with wound cleanser, pat dry, apply Betadine [used as an antiseptic for the treatment of common skin infections], gauze wrap with kerlex secure with paper tape .Cleanse wound to right medial foot with wound cleanser, pat dry, paint with betadine and apply [a type of wound dressing], gauze, [absorbant dressing] and, wrap with kerlex secure with paper tape .Paint right third toe with betadine except for bone, place silver alginate between toes, cover exposed bone with [a specialized product for wound care], cover with gauze, wrap in kerlex, secure with paper tape Monday, Wednesday, and Friday . Review of a Physician Order dated [DATE], showed .TREATMENT TO R [RIGHT] LATERAL AND MEDIAL FOOT .APPLY BETADINE . During an observation of wound care on [DATE] at 9:45 AM, Wound care Licensed Practical Nurse (LPN) gathered the wound care supplies, provided wound care as ordered to include applying betadine to the right foot. Observation of the betadine used by LPN Wound Care showed it had expired on ,d+[DATE]. During an interview on [DATE] at 9:55 AM, the Wound Care LPN confirmed the betadine used on Resident #40's right foot was out of date and expired ,d+[DATE]. During an interview on [DATE] at 10:33 AM, the Medical Director stated the expired betadine would not delay wound healing. During an interview on [DATE] at 2:01 PM, the Pharmacist stated he researched the manufacturer of the betadine, and found the expiration date was not a firm not use by date. The Pharmacist stated, in his professional opinion, use of the betadine that expired ,d+[DATE] would not cause a delay in wound [NAME]. During an interview on [DATE] at 3:30 PM, the Director of Nursing (DON) confirmed the facility used expired betadine solution to treat Resident #40's right foot wounds and did not meet the facility's expectations.

Based on record review, observation, and interview, the facility failed to follow a physician's order for a pressure reducing device for 1 resident (Resident #45) of 3 residents reviewed for pressure ulcers. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Presence of a Left Artificial Hip Joint, Dementia, Pressure-Induced Deep Tissue Damage of the Left Heel, and Encounter for Palliative Care. Review of the Braden Scale assessment dated [DATE], showed a score of 16, which indicated Resident #45 was at risk for skin breakdown. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score was 4, which indicated Resident #45 had severe cognitive impairment, required limited one person assistance with bed mobility, had risk of pressure ulcers present, had the presence of an unstageable deep tissue injury (DTI), utilized a pressure reducing device, and had received hospice care. Review of a Weekly Skin Observation dated 8/29/2023, showed Resident #45's wound (left heel) measured 1.5 centimeters (cm) x 2.0 cm and was non-blanchable with purple discoloration. Review of the current physician's orders dated 9/2023, showed Paint DTI [deep tissue injury] to Left (L) Heel with Betadine four times a day. Patient to have L Heel Protector on when in bed. During an observation on 9/12/2023 at 2:05 PM, Resident #45 was lying in bed and the left heel protector was not in place. During an observation on 9/13/2023 at 10:25 AM, Resident #45 was lying in bed and the left heel protector was not in place. During an interview on 9/13/2023 at 10:26 AM, the Wound Care Licensed Practical Nurse (LPN) confirmed Resident #45 did not have the left heel protector in place. The Wound Care LPN stated, .I'm not sure why but I will find out . During an interview on 9/13/2023 at 3:30 PM, the Director of Nursing (DON) confirmed the facility failed to follow the physician orders related to heel protector to the left heel while in bed.

Based on facility policy review, medical record review, and interview the facility failed to update a comprehensive care plan to include an identified need for 1 resident (Resident #9) out of 22 residents reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 2/2023, showed .Decision making/planning is based on identified needs/problems and builds on patient strengths while taking into account the patient's preferences . Resident #9 was admitted to the facility on [DATE] with diagnoses including Moderate Protein-Malnutrition, Fracture Left Humerus, Mass Upper Right Limb, and Osteoporosis. Review of Resident #9's comprehensive care plan dated 8/16/2023 showed no prompted toileting had been added as an intervention for bladder incontinence due to bladder leakage. Review of Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] showed resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact and was frequently incontinent of bowel and bladder. Review of Resident #9's Bowel and Bladder assessment dated [DATE], showed the resident was not always incontinent of bowel and bladder, a score of 10 indicated resident was a candidate for scheduled/prompted toileting. During an interview on 9/12/2023 at 3:23 PM, Resident #9 revealed the staff do not offer to take me to the bathroom, they just change me when I am wet, I would like to go to the bathroom. During an interview on 9/12/2023 at 3:35 PM, Certified Nurse Aide (CNA) #1, revealed .I have received no instructions to do prompted toileting for the resident . During an interview on 9/12/2023 at 3:45 PM, Registered Nurse Unit Manager #2 confirmed prompted toileting had not been added to the care plan and was not implemented as an intervention for Resident #9.

Based on facility policy review, medical record review, and interview the facility failed to implement the comprehensive care plan for 1 resident (Resident #45) related to wounds of 3 residents reviewed for wounds. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses including, Left Femur Fracture, History of Falling, Dementia, and Pressure Induced Deep Tissue Damage of Left Heel. Review of a Physician Order dated 8/15/2023, showed .PATIENT TO HAVE L [LEFT] HEEL PROTECTOR ON WHEN IN BED . Review of Resident #45's comprehensive care plan dated 8/15/2023, showed .PATIENT TO HAVE L HEEL PROTECTOR ON WHEN IN BED . During an observation on 9/13/2023 at 10:25 AM, Resident #45 was lying in bed and the left heel protector was not in place. During an interview on 9/13/2023 at 10:26 AM, the wound care Licensed Practical Nurse confirmed Resident #45 did not have the left heel protector in place I'm not sure why but I will find out. During an interview on 9/13/2023 at 3:30 PM, the Director of Nursing confirmed the facility failed to implement the care plan for Resident #45 related to heel protector in place to the left heel while in bed.

Based on facility policy review, record review, observation and interview, the facility failed to provide a summary of the baseline care plan to 1 resident (Resident #218) of 24 residents reviewed for baseline care plans. The findings include: Review of the facility's policy titled, Nursing Services, dated 2/2023, showed .A baseline care plan is developed to address the immediate needs .within 48 hours of .admission .summary of the baseline care plan will be shared with the patient and the representative . Resident #218 was admitted to the facility on [DATE] with diagnoses including Traumatic Subdural Hemorrhage, History of Falling and Depression. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #218 was cognitively intact. During an interview on 9/12/2023 at 8:19 AM, Resident #218 stated she did not receive a summary of her baseline care plan. Record review showed no documentation Resident #218 received a summary of her baseline care plan. During an interview on 9/13/2023 at 11:23 AM, the Social Services Coordinator (SSC) stated she interviewed the resident on 8/28/2023 and discussed her medical history and her discharge plan. The SSC stated the RN Unit Manager was responsible for reviewing the baseline care plan with the cognitively intact resident. The SSC confirmed there was no documentation that the resident was given a summary of the baseline care plan and that the Resident was cognitively intact.

Based on record review, observation and interview, the facility failed to provide services necessary to maintain a sanitary, orderly, and comfortable interior for 5 residents (Residents #10, #217, #226, #324 and #318) of 91 residents reviewed for environment. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, History of Falling and Depression and resided in room [ROOM NUMBER] bed A. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #10 had moderate cognitive impairment. Resident #217 was admitted to the facility on [DATE], with diagnoses including History of Falling, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus and resided in room [ROOM NUMBER] bed B. Review of an entry MDS assessment dated [DATE] showed Resident #217 was cognitively intact. During an observation and interview on 9/11/2023 at 11:48 AM, in room [ROOM NUMBER], a portable air conditioning unit was positioned on the floor by the window. The unit had a white, plastic, flexible exhaust pipe attached to the unit, and the pipe extended through an open window. The pipe had a plastic frame to secure it in the window between the sash and sill. The poorly fitting pipe frame resulted in cracks, through which the outdoors could be seen, and the cracks were filled with bath towels. The towels were yellowed and soiled. The privacy curtain was open and both residents, Residents #10 and #217 could see the portable unit. Resident #217 stated it had been like that since she was admitted (12 days previous), and the towels had not been changed. Resident #226 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Pneumonitis and Chronic Kidney Disease and resided in room [ROOM NUMBER] bed B. Review of an admission MDS dated [DATE] showed Resident #226 was cognitively intact. During an observation on 9/11/2023 at 3:30 PM, in room [ROOM NUMBER], a portable air conditioning unit was positioned on the floor by the window, and it had a flexible exhaust pipe extending out through the window. Bath towels were crumpled up in the void between the plastic frame holding the exhaust pipe and the window sash. The towels were dirty, yellowed and damp. The resident stated she wasn't aware of how long the unit had been there. The privacy curtain was closed, and the roommate stated she never saw the portable unit. During an observation on 9/13/2023 at 9:40 AM, in room [ROOM NUMBER], the portable air conditioning unit and towels were still in place, and the privacy curtain was closed. Resident #324 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of the Right Popliteal Vein and Glaucoma and resided in room [ROOM NUMBER]. Review of an admission MDS assessment dated [DATE] showed Resident #324 was cognitively intact. During an observation and interview on 9/11/2023 at 1:50 PM, room [ROOM NUMBER] had a portable heating and air unit beside the window that had an exhaust pipe attached to an exterior window. There were towels placed around the exhaust pipe that were damp and had brownish yellow stains. The resident stated the portable heating and air unit had been there since she admitted to the facility (3 days previous), and the staff had placed towels around the exhaust pipe to absorb condensation. During an observation on 9/12/2023 at 9:35 AM, in room [ROOM NUMBER], towels were still around the exhaust pipe that were damp with brownish yellow stains present. During an observation and interview on 9/12/2023 at 1:56 PM, with the Maintenance Director in rooms 355, 361 and 413, the Director stated the facility was forced to provide portable heating and air units because the air conditioning system in those rooms was not working properly. The towels were used to fill the cracks around the frame to keep water and insects out. The Maintenance Director observed the towels pushed in the cracks to be yellowed and dirty and confirmed the towels filling the cracks around the exhaust pipe in rooms 355, 361 and 413 were unsanitary and did not maintain an orderly and homelike environment. Resident #318 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis, Immunodeficiency, and Obesity and resided in room [ROOM NUMBER]. Review of an admission MDS assessment dated [DATE] showed Resident #318 was cognitively intact. During an observation on 9/11/2023 at 1:35 PM, room [ROOM NUMBER] had a foul odor, and there were 2 large dark-brown stains, approximately 12 inches in diameter, on the carpet at the bottom right side of the resident's bed. During an interview on 9/11/2023 at 1:38 PM, Resident #318 stated there was a strong smell in her room (room [ROOM NUMBER]) which had been present during her entire stay at the facility. The resident stated when her family or guests came to visit her, they would complain about the smell to her. The resident stated in her opinion, the odor reminded her of cooked broccoli and garlic. During an observation on 9/12/2023 at 9:30 AM, room [ROOM NUMBER] continued to have a robust odor consistent with that of cooked vegetables. During an interview on 9/12/2023 at 2:20 PM, in room [ROOM NUMBER], the Housekeeping Director stated there was an unknown odor in room [ROOM NUMBER] which could be related to the dark-brown stains on the carpet. During an interview on 9/12/2023 at 2:23 PM, the Maintenance Director stated Resident #318's room had an .unknown odor with unknown stains . present on the carpet. The Maintenance Director stated he did not know where the odor was coming from but thought it could be from the carpet which needed to be shampooed. The Maintenance Director confirmed Resident #318's room was not consistent with a home-like environment. 48100

Based on medical record review and interview the facility failed to provide scheduled/prompted toileting, a Bowel and Bladder need identified for 1 resident (Resident #9) out of 22 residents reviewed. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses including Moderate Protein-Malnutrition, Fracture Left Humerus, Mass Upper Right Limb, and Osteoporosis. Review of Resident #9's Comprehensive Care Plan dated 8/16/2023, showed no prompted toileting had been added as an intervention for bladder incontinence due to bladder leakage. Review of Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] showed resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact and was frequently incontinent of bowel and bladder. Review of Resident #9's Bowel and Bladder assessment dated [DATE], showed the resident is not always incontinent of bowel and bladder, a score of 10 indicated resident was a candidate for scheduled/prompted toileting. During an interview on 9/12/2023 at 3:23 PM, Resident #9 revealed, the staff do not offer to take me to the bathroom, they just change me when I am wet, I would like to go to the bathroom. During an interview on 9/12/2023 at 3:35 PM, Certified Nurse Aide (CNA) #1 revealed .I have received no instructions to do prompted toileting for the resident . During an interview on 9/12/2023 at 3:45 PM, Registered Nurse Unit Manager #2 confirmed scheduled/prompted toileting had not been added to the care plan and was not implemented as an intervention for Resident #9. During an interview on 9/13/2023, the MDS Coordinator revealed the scheduled/prompted toileting need, identified through the Bowel and Bladder assessment dated [DATE], was used as guidance. The facility was not required to provide the intervention due to the resident had admitted to the facility with bladder leakage and wore briefs at home. Further interview confirmed no formal scheduled/prompted Bowel and Bladder program had been implemented for Resident #9.

Based on facility policy review, observation and interview, the facility failed to dispose of garbage and refuse properly in 1 of 2 dumpsters. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, showed .WASTE MANAGEMENT .Receptacles and waste handling units shall be kept covered .after they are filled .Dumpsters will be checked routinely for cleanliness .debris .Doors are to be kept closed except during use . An observation of 2 dumpsters on 9/11/2023 at 11:05 AM, with the Dietary Manager and the Regional Dietician, showed the left dumpster was full, contained food containers and was uncovered. Food containers were found on the ground around the dumpster attracting flies and bees. During an interview on 9/11/2023 at 11:10 AM, the Dietary Manager confirmed the area around the dumpster was littered with food containers and the left dumpster was not covered, which allowed pests to enter, and was not a sanitary environment.

Based on facility policy review, Centers for Disease Control and Prevention (CDC) guidance, observation, and interview the facility failed to properly prevent COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) by failing to implement universal use of eye protection as part of Personal Protective Equipment (PPE) during all patient care encounters in a community with high COVID-19 transmission which had the potential to result in COVID-19 transmission to 84 of 96 residents in the facility. The findings include: Review of the facility's policy titled, INFECTION CONTROL MANUAL, dated 1/10/2020, showed .The Infection Prevention and Control Program is comprehensive in that it addresses detection, control and prevention of infections .policies and procedures are developed for practice by partners to aid in the prevention and control of infectious processes .all centers will have a functioning Infection Control Committee .This committee will oversee the implementation of guidelines and procedures based on guidelines established by CDC, CMS [Centers for Medicare & Medicaid Services] .for prevention and management of infection and disease . Review of the facility's titled, 904 COVID-19 ([CONDITION(S)]-CoV-2), dated 8/2021, showed .CORE PRINCIPLES of COVID-19 INFECTION PREVENTION .Core Principles of COVID-19 Infection Prevention during the Public Health Emergency .Appropriate staff use of Personal Protective Equipment (PPE) . Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/10/2021, showed .The guidance applies to all U.S. settings where healthcare is delivered .IPC [infection prevention and control] (e.g. [example], use of source control, screening testing) are influenced by levels of [CONDITION(S)]-CoV-2 transmission in the community .Implement Source Control Measures .Source control refers to use of respirators or well-fitting facemasks .Implement Universal Use of Personal Protective Equipment for HCP .If [CONDITION(S)]-Cov-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP [Healthcare Personnel] working in facilities located in counties with substantial or high transmission should also use PPE as described below .Eye protection (i.e. [that is], goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Review of the CDC COVID Data Tracker on 2/1/2022 showed the facility was located in a county with high community COVID-19 transmission. Observation and interview on 2/1/2022 at 11:59 AM, showed Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 in a resident's room on the 400 hallway providing resident care wearing surgical masks and no eye protection. LPN #1 and RN #1 confirmed eye protection is only required when caring for COVID-19 positive and suspected COVID-19 positive residents. Observation and interview on 2/1/2022 at 12:04 PM, showed Certified Nursing Assistant (CNA) #1 in a resident's room on the 400 hallway providing resident care. CNA #1 wore a surgical mask and no eye protection. CNA #1 confirmed eye protection is only required for the care of COVID-19 residents. Observation on 2/1/2022 at 12:06 PM, showed an unidentified staff member in a resident's room on the 400 hallway providing resident care. The unidentified staff member wore a surgical mask and no eye protection. Observation and interview on 2/1/2022 at 12:10 PM, showed Occupational Therapist (OT) #1 in a resident's room on the 400 hallway providing therapy. OT #1 wore a surgical mask and no eye protection. OT #1 confirmed eye protection is only worn for residents on droplet precautions. During an interview on 2/1/2022 at 3:02 PM, the Director of Nursing (DON) and the Quality Assurance Director confirmed the facility was not currently experiencing any PPE shortages and was located in a county with high community COVID-19 transmission. Observation and interview on 2/2/2022 from 9:42 AM - 9:59 AM, showed Occupational Therapy Assistant (OTA) #1 and Physical Therapy Assistant (PTA) #1 providing therapy to a resident on the 300 hallway. The 2 staff members provided ambulation assistance, hydration, and breakfast tray set up assistance and wore surgical masks and no eye protection during the patient care encounter. OTA #1 and PTA #1 confirmed eye protection is only required to be worn during patient care encounters for residents on droplet precautions. Observation and interview on 2/2/2022 at 9:53 AM, showed LPN #2 in a resident's room on the 300 hallway. LPN #2 obtained vital signs and administered medications to the resident and wore a surgical mask and no eye protection. LPN #2 confirmed eye protection was not required for the care of all residents and was only worn for residents in isolation. During an interview on 2/2/2022 at 10:22 AM, the DON confirmed eye protection was not currently worn for all patient care encounters. Masks were always required, and eye protection was only required for the care of COVID-19 positive and COVID-19 suspected positive residents. Further interview with the DON confirmed she was aware of the CDC recommendation for the universal use of eye protection for all patient encounters in communities with high COVID-19 transmission and stated, that is a recommendation and not a requirement. During an interview on 2/2/2022 at 10:50 AM, the Administrator stated it was her expectation that CDC guidance is followed as much as possible.

Based on medical record review and interview, the facility failed to provide a comprehensive discharge plan for one resident (Resident #1) of 3 residents reviewed. The findings include: Medical record review showed Resident #1 was admitted to the facility from the hospital on [DATE] with Traumatic Subarachnoid Hemorrhage without Loss of Consciousness, Cerebral [MEDICAL CONDITION], and Facial Fractures, because of a Fall. Medical record review showed there was no documentation of Resident #1 having any pressure ulcers on admission, and there were no treatment orders for a pressure ulcer obtained from the physician on admission. Medical record review revealed a nursing progress note dated 10/13/2020, Open area noted to coccyx (tailbone area) measuring 1.5 cm (centimeters) by 1.0 cm by 0.1 cm. Wound base moist and beefy red. Bleeds easily. Treatment initiated and wound care nurse notified. Medical record review of a physician's orders [REDACTED]. Pat dry. Apply [MEDICATION NAME] (a wafer type of dressing that consists of an adhesive compound filled with gel-forming agents, which is laminated onto a flexible outer layer of bandage). Change every 3 days and PRN (as needed). Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was cognitively intact, required extensive assistance of 2 persons for bed mobility, and required extensive assistance of 1 person for transfer. The Wound Care Nurse documented the resident had 1 unstageable deep tissue pressure ulcer that was present on admission (10/8/2020). Review of the facility Monthly Pressure Ulcer Worksheet October 2020, used to document resident wound descriptions, documentation for 10/15/2020 showed Resident #1 had an unstageable Deep Tissue Injury to the coccyx measuring 2 cm. length by 2 cm. width. Medical record review of Resident #1's Wound Management, the facility documentation for Resident #1's wounds, showed the Wound Nurse documented on 10/15/2020 .Pressure Ulcer .Coccyx was Identified on 10/9/2020 at 12:27 PM. The Wound Nurse documented on 10/15/2020 at 12:27 PM, .Date/Time Observed: 10/09/2020 12:27 PM .Length .2 (cm) Width .2 (cm) Can depth be measured?: No Exudate Amount: None Stage: Unstageable - Deep Tissue Undermining present?: No Sinus tract/tunneling present: No Tissue Type: [MEDICATION NAME] Tissue (thin skin layer) Skin surrounding wound .Pink/Normal .Wound healing status: Stable . Review of the facility Monthly Pressure Ulcer Worksheet October 2020, for Week 4, dated 10/15/2020, showed Resident #1 had an unstageable Deep Tissue Injury to the coccyx measuring 1.8 cm. length by 1.5 cm. width. Medical record review of Resident #1's Wound Management dated 10/19/2020 at 5:09 PM revealed .Date/Time Observed: 10/16/2020 05:08 PM Length .2 (cm) Width .1.7 (cm) .Exudate Amount: Light Exudate color and consistency: Serosanguineous (pale red to pin, thin and watery) .Unstageable - Slough and/or Eschar Tissue Type: Slough .Wound healing status: Stable . Medical record review of a treatment order dated 10/19/2021 showed the treatment for [REDACTED].apply [MEDICATION NAME] (medicated wound dressing), cover with bordered dressing daily . Medical record review of Resident #1's Wound Management dated 10/26/2020 at 10:23 AM showed, .Date/Time Observed 10/23/2020 10:22 AM Length .2 (cm) Width .1.8 (cm) .Depth . 0.1 (cm) Exudate Amount: Light Exudate color and consistency: Serous (clear, amber, thin and watery) Wound odor present?: No .Unstageable - Sough and/or Eschar Tissue Type: Sough .Wound healing status: Stable . Medical record review showed the Wound Care Nurse documented on 10/23/2020 Resident #1's pressure ulcer had deteriorated in healing. Medical record review showed on 10/25/2020, 3 days prior to Resident #1's discharge, Licensed Practical Nurse (LPN #3) documented the pressure ulcer had purulent drainage and necrotic tissue present. Review of the facility Monthly Pressure Ulcer Worksheet October 2020, for Week 5, dated 10/28/2020, showed Resident #1 had an unstageable Deep Tissue Injury to the coccyx measuring 2 cm. length by 1.8 cm. width. Medical record review of the nursing progress notes by the Wound Care Nurse dated 10/27/2020 showed the first documentation the family was notified of Resident #1's pressure ulcer, Spoke with son regarding wound care orders for discharge, discussed plans for .wound care from (name of home health agency) . Medical record review of the Nurse Practitioner (NP) Documentation of Face to Face Encounter dated 10/27/2020 at 12:52 PM showed the resident was to be discharged home. Under Review of Systems information obtained by the resident and facility staff, the NP documented Resident #1 did not have any wounds. Under the Physical Exam, the NP documented No Ulcer .Other - See nurses notes for further detail regarding skin assessment. Medical record review of the 10/28/2020 nursing progress note showed the entry, .discharged with home health .Dressing supplies and instructions per wound care nurse. Medical record review of the Transition of Care/Discharge Summary dated 10/28/2020 showed, .Clinical Discharge and Narrative .Pressure Ulcer/Injury Risk of Pressure Ulcers/Injuries - Yes; Unhealed Pressure Ulcers/Injuries - Yes .Care Plan Goals Goal Date .11/08/2020 Will have risks related to compromised skin integrity addressed and complications minimized; and/or skin condition/wounds will exhibit signs of improvement .General Order .apply [MEDICATION NAME], cover with bordered dressing daily . Review revealed there was no other documentation regarding the pressure ulcer and no description of the wound. Medical record review of the discharge MDS dated [DATE], showed Resident #1 was documented as having been discharged with an unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar. Telephone interview with a Home Health Agency Administrator on 1/28/2021 at 10:30 AM, confirmed Resident #1 was referred to their agency for continued care after discharge from the nursing home on 10/28/2020. During interview, the Administrator stated the agency was not notified of Resident #1's coccyx pressure ulcer. The Administrator stated even the Face to Face assessment conducted by the nursing home's Nurse Practitioner on 10/27/2020, did not document a pressure ulcer. The Administrator stated on 10/29/2020, the home health Registered Nurse (RN) arrived at Resident #1's home, assessed the coccyx pressure ulcer, and reported back to the Administrator the pressure ulcer had the presence of infection. The Administrator received the RN's verbal report and photographs and decided not to admit Resident #1. During the initial home health visit, Resident #1's family Resident #1 needed to be admitted to the hospital. Telephone interview with the Director of Nursing (DON) on 1/28/2021 at 3:45 PM, confirmed the Face to Face assessment performed by the nursing home Nurse Practitioner on 10/27/2020 did not document the presence of a pressure ulcer. The DON confirmed the Transition of Care/Discharge Summary dated 10/28/2020 did list an Unhealed Pressure Ulcer, but did not provide any further information related to location, size, or condition of the pressure ulcer.

Based on facility policy review, medical record review, and interview, the facility failed to provide timely notification to the physician and the family of 1 resident's pressure ulcer (Resident #1) of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility's policy Pressure Ulcer Assessment & Treatment Guidelines revealed, .Comprehensive wound assessment .Physician/Practitioner notified promptly/timely of indications of lack of wound healing, deterioration in wound healing or newly identified signs or symptoms of infection .Patient/family involvement in the development of the plan of care .Notification of family of physician contact .Patients and families are to be kept current related to wound healing . Medical record review showed Resident #1 was admitted to the facility from the hospital on [DATE] with Traumatic Subarachnoid Hemorrhage without Loss of Consciousness, Cerebral [MEDICAL CONDITION], and Facial Fractures, because of a Fall. Medical record review of the Admission assessment dated [DATE] showed, .admitted for therapy and medical management due to deconditioning with generalized weakness, decreased functional mobility related to recent fall .abrasions on his left shoulder, left elbow, left shin. Small skin tear on right elbow, left hip with purpura/ecchymotic (bruising) .Pressure redistributing mattress and wheelchair cushion provided for skin breakdown prevention .alert, oriented, able to make needs known . The Admission Assessment did not document any wounds or pressure ulcers for Resident #1. Medical record review of the physician's History and Physical dated 10/9/2020, showed No Ulcer .or other [MEDICAL CONDITION] . Medical record review showed there was no documentation of Resident #1 having any pressure ulcers on admission, and there were no treatment orders for a pressure ulcer obtained from the physician on admission. Medical record review revealed a nursing progress note dated 10/13/2020, Open area noted to coccyx (tailbone area) measuring 1.5 cm (centimeters) by 1.0 cm by 0.1 cm. Wound base moist and beefy red. Bleeds easily. Treatment initiated and wound care nurse notified. This documentation was the first documentation in the medical record the resident had a pressure ulcer. Medical record review showed a Nurse Practitioner received notice Resident #1 had a pressure ulcer and provided an order for [REDACTED].>Medical record review of a physician's orders [REDACTED]. Pat dry. Apply [MEDICATION NAME] (a wafer type of dressing that consists of an adhesive compound filled with gel-forming agents, which is laminated onto a flexible outer layer of bandage). Change every 3 days and PRN (as needed). Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was cognitively intact, required extensive assistance of 2 persons for bed mobility, and required extensive assistance of 1 person for transfer. The Wound Care Nurse documented the resident had 1 unstageable deep tissue pressure ulcer that was present on admission (10/8/2020), however, medical record documentation showed the first assessment of the wound and first treatment orders were dated 10/13/2020. Medical record review showed the first documentation the family was notified Resident #1 had a pressure ulcer was a progress note by the Wound Care Nurse on 10/27/2020, Spoke with son regarding wound care orders for discharge, discussed plans for .wound care from (name of home health agency) . Interview by telephone with Resident #1's nursing home physician on 1/29/2021 at 11:30 AM, showed the physician, the physician extenders and the discharging nurse practitioner had not been asked at any time during Resident #1's stay to assess the coccyx pressure ulcer. The physician confirmed the first physician order [REDACTED]. Interview with the Director of Nursing (DON) on 2/1/2021 at 2:45 PM, and review of the medical record confirmed the family was not notified of the pressure ulcer prior to 10/27/2020, one day prior to Resident #1's discharge.

Based on review of facility policy, medical record review, review of facility reports, and interview, the facility failed to provide accurate assessment, documentation and tracking of a pressure ulcer for 1 resident (Resident #1) of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility's Pressure Ulcer Assessment & Treatment Guidelines For All Patients With Pressure Ulcers revised 5/30/2014 revealed, .Prompt and timely implementation of MD (physician) orders and order changes .Monitoring of p.u. (pressure ulcer) (*with accompanying documentation, when a change is identified) *To include: evaluation of the ulcer, if no dressing is present; evaluation of dressing status & area surround ulcer; presence of complications; presence of pain . Medical record review showed Resident #1 was admitted to the facility from the hospital on [DATE] with Traumatic Subarachnoid Hemorrhage without Loss of Consciousness, Cerebral [MEDICAL CONDITION], and Facial Fractures, because of a Fall. Medical record review of the Admission assessment dated [DATE] showed, .admitted for therapy and medical management due to deconditioning with generalized weakness, decreased functional mobility related to recent fall .abrasions on his left shoulder, left elbow, left shin. Small skin tear on right elbow, left hip with purpura/ecchymotic (bruising) .Pressure redistributing mattress and wheelchair cushion provided for skin breakdown prevention .alert, oriented, able to make needs known . The Admission Assessment did not document any wounds or pressure ulcers for Resident #1. Medical record review of the physician's History and Physical dated 10/9/2020, showed No Ulcer .or other [MEDICAL CONDITION] . Medical record review showed there was no documentation of Resident #1 having any pressure ulcers on admission, and there were no treatment orders for a pressure ulcer obtained from the physician on admission. Medical record review of the Registered Dietician (RD) progress note, dated 10/9/2020, showed, .(Resident #1) appears thin/frail .muscle wasting to temporal .pectoral .BUE (bilateral upper extremities) and BLE (bilateral lower extremities). He appears to have thin skin and poor fat stores. Eyes appear sunken. No breakdown or [MEDICAL CONDITION] per nsg (nursing). BMI (body mass index) low .Based on RD meal observation and nutritional assessment .does not appear to currently meet nutritional needs .Offer house supplement 4 oz (ounces) bid (twice a day) . Medical record review revealed a nursing progress note dated 10/13/2020, Open area noted to coccyx (tailbone area) measuring 1.5 cm (centimeters) by 1.0 cm by 0.1 cm. Wound base moist and beefy red. Bleeds easily. Treatment initiated and wound care nurse notified. This documentation was the first documentation in the medical record the resident had a pressure ulcer. Medical record review of a physician's orders [REDACTED]. Pat dry. Apply [MEDICATION NAME] (a wafer type of dressing that consists of an adhesive compound filled with gel-forming agents, which is laminated onto a flexible outer layer of bandage). Change every 3 days and PRN (as needed). Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was cognitively intact, required extensive assistance of 2 persons for bed mobility, and required extensive assistance of 1 person for transfer. The Wound Care Nurse documented the resident had 1 unstageable deep tissue pressure ulcer that was present on admission (10/8/2020), however, medical record documentation showed the first assessment of the wound and first treatment orders were dated 10/13/2020. Review of the facility Monthly Pressure Ulcer Worksheet October 2020, used to document resident wound descriptions, showed Resident #1 was not documented on the report as having any wounds until Week 3, dated 10/15/2020. The report for 10/15/2020 showed Resident #1 had an unstageable Deep Tissue Injury to the coccyx measuring 2 cm. length by 2 cm. width. The resident was on an air mattress. Medical record review of Resident #1's Wound Management, the facility documentation for Resident #1's wounds, showed the report was created on 10/15/2020 at 12:27 PM and was the first documented wound notes from the Wound Care Nurse. The Wound Nurse documented on 10/15/2020 .Pressure Ulcer .Coccyx was Identified on 10/9/2020 at 12:27 PM. The Wound Nurse documented on 10/15/2020 at 12:27 PM, .Date/Time Observed: 10/09/2020 12:27 PM (6 days before the Wound Management documentation was created) .Length .2 (cm) Width .2 (cm) Can depth be measured?: No Exudate Amount: None Stage: Unstageable - Deep Tissue Undermining present?: No Sinus tract/tunneling present: No Tissue Type: [MEDICATION NAME] Tissue (thin skin layer) Skin surrounding wound .Pink/Normal .Wound healing status: Stable . Review of the medical record showed no documentation the physician was notified the resident had a Deep Tissue Injury, no treatment orders were obtained, and no treatment was initiated for the wound when identified on 10/9/2020. The Wound Management record was created 6 days after the Wound Nurse indicated the wound was discovered, and 2 days after the documented wound description on 10/13/2020 with treatment interventions implemented and notification to the Wound Care Nurse. Review of the facility Monthly Pressure Ulcer Worksheet October 2020, for Week 4, dated 10/15/2020, showed Resident #1 had an unstageable Deep Tissue Injury to the coccyx measuring 1.8 cm. length by 1.5 cm. width. Medical record review of Resident #1's Wound Management dated 10/19/2020 at 5:09 PM revealed .Date/Time Observed: 10/16/2020 05:08 PM Length .2 (cm) Width .1.7 (cm) .Exudate Amount: Light Exudate color and consistency: Serosanguineous (pale red to pin, thin and watery) .Unstageable - Slough and/or Eschar Tissue Type: Slough .Wound healing status: Stable . Medical record review of a treatment order dated 10/19/2021 showed the treatment for [REDACTED].apply [MEDICATION NAME] (medicated wound dressing), cover with bordered dressing daily . Medical record review of Resident #1's Wound Management dated 10/26/2020 at 10:23 AM showed, .Date/Time Observed 10/23/2020 10:22 AM Length .2 (cm) Width .1.8 (cm) .Depth . 0.1 (cm) Exudate Amount: Light Exudate color and consistency: Serous (clear, amber, thin and watery) Wound odor present?: No .Unstageable - Sough and/or Eschar Tissue Type: Sough .Wound healing status: Stable . Review of the facility Monthly Pressure Ulcer Worksheet October 2020, for Week 5, dated 10/28/2020, showed Resident #1 had an unstageable Deep Tissue Injury to the coccyx measuring 2 cm. length by 1.8 cm. width. Medical record review of the Nurse Practitioner (NP) Documentation of Face to Face Encounter dated 10/27/2020 at 12:52 PM showed the resident was to be discharged home. Under Review of Systems information obtained by the resident and facility staff, the NP documented Resident #1 did not have any wounds. Under the Physical Exam, the NP documented No Ulcer .Other - See nurses notes for further detail regarding skin assessment. Medical record review of hospital records showed Resident #1 was admitted to the hospital for acute care on 10/30/2020 with [DIAGNOSES REDACTED]. Medical record review of the surgeon's operative report, dated 10/31/2020, showed, .Preoperative Diagnosis: [REDACTED].Procedure: 1. Sharp excisional debridement of skin, fat, muscle, fascia, bone sacrum (6.5 cm x 10 cm x 3 cm) 2. Coccygectomy (removal of the coccyx bone) .4. Negative pressure wound dressing to the sacrum . Medical record review of Resident #1's hospital discharge, dated 11/14/2020, showed, Assessment:[MEDICAL CONDITION] (secondary to infected sacral decubitus ulcer) .continue IV (intravenous) abx (antibiotics) .status [REDACTED].coli (Escherichia coli)) .Sacral Decubitus Ulcer with Abscess .continue wound vac .Acute [DIAGNOSES REDACTED] of Sacrum .will need outpatient IV abx therapy . Interview with Licensed Practical Nurse (LPN) #1 on 1/27/2021 at 4:50 PM, showed the LPN had conducted the admission assessment of Resident #1 and did not see any wounds on the sacral/coccyx area during that admission assessment. During interview with LPN #2 on 1/27/2021 at 4:20 PM, LPN #2 stated the pressure ulcer she documented on 10/13/2020 was not present prior to 10/13/2020. LPN #2 stated the wound had a depth of 0.1 cm and was beefy red without any necrotic tissue present. During interview with the Director of Nursing (DON) on 1/27/2021 at 5:00 PM, the DON stated the Wound Care Nurse was no longer employed at the facility and had not shared information about the presence of, or condition of, Resident #1's wounds during the facility's weekly meetings. Interview with the DON and the corporate Consultant on 1/28/2021 at 3:50 PM confirmed the Wound Care Nurse did not document any wound assessments prior to 10/15/2020 and then indicated the wound was present on admission and observed on 10/9/2020. During telephone interview with Resident #1's nursing home physician on 1/29/2021 at 11:30 AM, the physician stated the resident was .frail guy .someone that thin the wound can come on fast . The physician confirmed the physician and the NPs had not been notified of or asked to assess a pressure ulcer on the resident's coccyx. Interview with LPN #2 on 2/1/2021 at 12:17 PM, showed treatment and dressing changes were performed by the unit nurse assigned to the resident and she frequently changed the dressing. LPN #2 stated, .Sometimes it would have feces in it .because of where it was .no slough or necrotic tissue noted .he would get himself onto his back .

Based on facility policy review, medical record review and interview the facility failed to reconcile medications at discharge for 2 residents (#1 and #3) of 8 residents reviewed for Admission, Transfer and Discharge. The findings include: Review of the facility policy, titled, Discharge with Medications, undated, showed .Medications may be sent with the resident on discharge if ordered .by the prescriber. The order should list the medications to be released upon discharge .The labeling on discharge medications is verified for completeness and accuracy by reconciling them against the most recent physician's orders . Review of Resident #1's medical record showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's medical record showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Discharge Physician's orders dated 5/28/2020 showed the following medications: [REDACTED] - Atorvastatin (medication to treat high cholesterol/ triglyceride levels) 10 milligrams (mg) tablet - [MEDICATION NAME] (medication to treat fluid retention) 40 mg tablet - Xarelto (medication to prevent blood clots) (rivaroxaban) 20 mg tablet - [MEDICATION NAME] (medication to aid sleep) 3 mg tablet Review of photos received showed Resident #1's family was in possession of the following medications labeled and prescribed for Resident #7: -Atorvastatin 10 mg/[MEDICATION NAME] 10 mg) tablet, Give 1 tablet by mouth at bedtime. -Xarelto 20 mg tablet, Give 1 tablet by mouth every evening. -[MEDICATION NAME] 3 mg tablet. Give 1 tablet by mouth at bedtime as needed for sleep. -[MEDICATION NAME] 40 mg tablet. Give 1 tablet by mouth once daily. Review of Resident #1's Discharge Physicians Orders dated 6/10/2020 showed the following medications: [REDACTED] -Ademelog [MEDICATION NAME] U-100 Insulin (insulin [MEDICATION NAME]) insulin (medication to treat diabetes) pen;100 unit/milliliter (mL) per sliding scale - Amiodipine (medication to treat high blood pressure) 5 mg tablet, once a day -Atorvastatin (medication to treat high cholesterol) 40 mg tablet at bedtime - Carvedilol (medication to treat high blood pressure) 12.5 mg, tablet twice a day - Ezetimibe (medication to treat high cholesterol) once a day - [MEDICATION NAME] M20 (potassium chloride) (medication to treat low levels of potassium) extended release, 20 milliequivalents (mEq) (unit of measure) tablet once a day - [MEDICATION NAME] (medication to treat under functioning [MEDICAL CONDITION]) 112 micrograms (mcg) tablet, once a day - Tamsulosin (medication to treat enlarged prostate) 0.4 mg capsule at bedtime - Aspirin 9medication to prevent blood clots) 81 mg tablet, once a day - [MEDICATION NAME] (antiplatelet medication to prevent blood clots) 75 mg tablet, once a day - [MEDICATION NAME] (medication to treat gout and kidney stones) 100 mg tablet, once a day -[MEDICATION NAME]-[MEDICATION NAME] (medication to treat allergies [REDACTED]. -Tresiba FlexTouch U-200 (insulin degludec) insulin pen: 200 unit/mL (3mL), 80 units subcutaneously (under the skin) once a day - [MEDICATION NAME] (medication to treat low iron) 325 mg tablet, once a day - [MEDICATION NAME] (vitamin D3) (medication to treat low 125 mcg (5,000 unit) capsule once a day - [MEDICATION NAME] (medication to treat fluid retention) 20 mg tablet, twice a day - [MEDICATION NAME] (medication to treat pain) 650 mg tablet for pain/fever every 8 hours as needed - [MEDICATION NAME] (medication to treat spasms) 10 mg tablet three times a day as needed - [MEDICATION NAME] Sodium (medication to prevent constipation) 100 mg tablet twice a day as needed for constipation -[MEDICATION NAME] (polyethylene [MEDICATION NAME]) (medication to treat constipation) powder: 17 grams (1 capful) mix with 4-8 oz water or juice, once a day as needed. - [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) (medication to treat pain) 5-325 mg tablet every 6 hours as needed During a telephone interview with Resident #1's family member on 9/16/2020 at 1:00 PM, the familiy member stated she was present with Resident #1's upon his discharge from the facility on 6/10/2020. She stated there were medications for both Resident #1 and Resident #7 sent home with Resident #1 on 6/10/2020. She stated she notified the facility of the error. During a telephone interview with Resident #1 on 9/17/2020 at 3:25 PM, he stated he was discharged from the facility on 6/10/2020 with a medication list and numerous medications in a bag. Resident #1 stated his family member was at his home at discharge to assist him with his medications and the bag contained medications for Resident #1 and Resident #7. Review of Resident #3's medical record showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Discharge Physician's orders dated 6/5/2020 showed the following medications; - [MEDICATION NAME] (medication to treat heart rhythm problems) 200 mg tablet -Atorvastatin 80 mg tablet -[MEDICATION NAME] cream; 0.025 % -Duloxetine (medication to treat depression and nerve pain) delayed release 60 mg tablet -[MEDICATION NAME] (a [MEDICATION NAME] used to improve digestion) 250 mg capsule Review of Resident #8's medical record showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Discharge Physician's orders dated 5/21/2020 showed Physicians Orders for the following: - [MEDICATION NAME] (medication to treat stomach acid) 24 HR, 20 mg delayed release capsule. Special Instructions: administer 1 twice a day (BID) x 1 week, then return to original dose twice a day. -[MEDICATION NAME] (medication to treat high blood pressure) 40 mg tablet twice a day. Review of Resident #11's medical record showed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's Discharge Physician's Orders dated 5/27/2020 showed a Physician's order for the following: [MEDICATION NAME] Sodium (medication to treat [MEDICAL CONDITION] Arthritis, Cancer and Psoriasis) 2.5 mg tablets (5 tablets) for total (12.5 mg) Once a day on Monday. Review of photo received showed of 3 medication bags with labels which were sent home on 6/5/2020 with Resident #3 at discharge showed 2 plastic medication bags labelled for Resident #8 as follows: -[MEDICATION NAME] 20 mg tablet. Give 1 tablet by mouth twice daily. - [MEDICATION NAME] 20 mg capsule. Give 2 capsules (40 mg) by mouth twice daily. Review of the same photo of medications sent home with Resident #3 showed 1 plastic medication bag labelled for Resident #11 as follows: -[MEDICATION NAME] 2.5 mg TAB. Give 5 tablets (12.5 mg) by mouth every Monday. During a telephone interview with Resident #3's family member on 9/15/2020 at 2:40 PM, she stated Resident #3 was discharged home to the family member on 6/5/2020 with 3 small bags with medications for Resident #8 and Resident #11. She stated she returned the medications to the facility. During an interview with Licensed Practical Nurse (LPN) #2 on 9/16/2020 at 3:00 PM, she stated she discharged Resident #1 and does not know how the resident received another resident's medications. The LPN stated the discharge process includes the Nurse Practitioner prints off the discharge medication report and reviews it, the discharge nurse gathers all left over medications that are not discontinued, including narcotics. The narcotics are signed out by 2 nurses and placed in a zip lock bag for the resident for discharge. The LPN stated she did not know the wrong medications were sent until the Director of Nursing (DON) told her. During an interview with LPN #1 on 9/16/2020 at 3:40 PM, she stated the Unit Coordinator was responsible for the discharge of residents. LPN #1 stated she discharged Resident #3 on 6/5/2020 and she was not aware other resident's medications were sent home with Resident #3. LPN #1 stated the process at discharge is to ensure discharge medications were correct and to verify the resident's medications upon discharge. During an interview with the DON on 9/21/2020 at 1:30 PM, she stated she received a message regarding the medications from Resident #1's family member. The DON stated she completed the in-service with nursing staff regarding the discharge of residents in the facility. The DON stated it is her expectation upon discharge all resident's prescribed medications were to be verified with the discharge Physicians Orders, reviewed with the resident or family, labelled and sent home with the resident. The DON stated any remaining medications that are not sent with the resident was to be disposed of by the nurse or the supervisor by the end of the shift. The DON stated residents are not charged for their medications.

Based on facility policy review, medical record review, and interview, the facility failed to ensure medications were administered in a timely manner and in accordance to professional nursing standards for 6 of 10 residents (Resident #56, #63, #72, #3, and #349, #191) reviewed for unnecessary medications. The findings include: Review of the facility policy titled, PREPARATION AND GENERAL GUIDELINES, dated 6/2016, showed Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered within 60 minutes before or after scheduled time. Unless otherwise specified by the prescriber . Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident Orders dated 1/1/2020 - 1/29/2020 showed Resident #56 was ordered the following: *[MEDICATION NAME] (an anti-anxiety medication) tablet 10 mg (milligrams) twice a day at 9:00 AM and 9:00 PM. *Carvedilol (heart medication) tablet 25 mg twice a day at 9:00 AM and 9:00 PM. *[MEDICATION NAME] (diuretic) tablet 40 mg twice a day at 9:00 AM and 9:00 PM. Review of Resident #56's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] tablet 10 mg was documented administered late as follows: *1/17/2020 at 11:32 AM (1 hour and 32 minutes late) resident was unavailable. *1/19/2020 at 11:12 PM (1 hour 12 minutes late) resident was unavailable. *1/22/2020 at 11:11 AM (1 hour and 11 minutes late) resident was unavailable. *1/29/2020 at 11:01 AM (1 hour and 1 minutes late) resident was unavailable. Review of Resident #56's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Carvedilol tablet 10 mg was documented administered late as follows: *1/4/2020 at 11:14 AM (1 hour and 14 minutes late) resident unavailable. *1/17/2020 at 11:32 AM (1 hour and 32 minutes late) resident unavailable. *1/18/2020 at 10:52 AM (59 minutes late) resident unavailable. Review of Resident #56's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] tablet 40 mg was documented administered late as follows: *1/22/2020 at 11:11 AM (1 hour and 11 minutes late) resident unavailable. *1/24/2020 at 11:05 AM (1 hour and 5 minutes late) resident unavailable. *1/26/2020 at 10:36 AM (36 minutes late) resident unavailable. During an interview on 1/30/2020 at 9:07 AM, Registered Nurse (RN) #3 confirmed she was assigned to Resident #56 several times in January. She confirmed Resident #56's medications were administered late several times in January. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #63's Orders dated 1/9/2020 - 1/29/2020 showed Resident #63 was ordered the following: *[MEDICATION NAME] (antiarrhythmic medication) tablet 200 mg once a day at 8:00 AM. *[MEDICATION NAME] (blood pressure medication) tablet 5 mg once a day at 8:00 AM. *Bisoprolo-[MEDICATION NAME] (high blood pressure medication) tablet 5-6.25 mg once a day at 8:00 AM. *[MEDICATION NAME] (anti-anxiety medication) tablet 0.5 mg twice a day at 8:00 AM and 8:00 PM. *[MEDICATION NAME] ([MEDICAL CONDITION] medication) 137 mcg (micrograms) once a day at 8:00 AM *[MEDICATION NAME] (muscle relaxer) tablet 500 mg twice a day at 8:00 AM and 8:00 PM. *[MEDICATION NAME] (Gout medication) 100 mg once a day at 8:00 AM. *[MEDICATION NAME] (diuretic medication) 40 mg twice a day at 8:00 AM and 8:00 PM. *[MEDICATION NAME] (antibiotic medication) 500/125 mg every 12 hours at 8:00 AM and 8:00 PM. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 200 mg was documented administered late as follows: *1/4/2020 at 9:38 AM (38 minutes late) resident was unavailable. *1/11/2020 at 9:25 AM (25 minutes late) resident was unavailable. *1/18/2020 at 1:30 PM (4 hour and 30 minutes late) resident was unavailable. *1/22/2020 at 9:39 AM (39 minutes late) resident was unavailable. *1/25/2020 at 9:27 AM (27 minutes late) patient care. *1/26/2020 at 9:55 AM (55 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 5 mg was documented administered late as follows: *1/17/2020 at 1:30 PM (4 hours and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Bisoprolo-[MEDICATION NAME] tablet 5-6.25 mg was documented administered late as follows: *1/28/2020 at 1:30 PM (4 hours and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 0.5 mg was documented administered late as follows: *1/18/2020 at 1:30 PM (4 hours and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 137 mcg was documented administered late as follows: *1/18/2020 at 1:30 PM (4 hour and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 500 mg was documented administered late as follows: *1/25/2020 at 9:27 AM (27 minutes late) patient care. *1/26/2020 at 9:55 AM (55 minutes late) patient care. *1/28/2020 at 9:44 AM (44 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 100 mg was documented administered late as follows: *1/4/2020 at 9:38 AM (38 minutes late) resident unavailable. *1/18/2020 at 1:30 PM (4 hours 30 minutes late) resident unavailable. *1/26/2020 at 9:55 AM (55 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] 40 mg documented administered late as follows: *1/4/2020 at 9:38 AM (38 minutes late) resident unavailable. *1/5/2020 at 10:14 PM (1 hour and 14 minutes late) patient care. *1/10/2020 at 10:10 PM (1 hour and 10 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020-1/29/2020 showed [MEDICATION NAME] 500-125 mg was documented administered late as follows: *1/18/2020 at 1:30 PM (4 hours and 30 minutes late) resident unavailable. During an interview conducted on 1/29/2020 at 4:55 PM, RN #4 confirmed she was assigned to Resident #63 several times in January. RN #4 confirmed the facility failed to administer Resident #4's medications within the 1 hour before or 1 hour after the scheduled medication times. During an interview on 1/29/2020 from 9:36 PM - 10:13 PM, the Director of Nursing (DON) stated medications should be given 1 hour before or 1 hour after the scheduled time. The DON confirmed the facility failed to ensure Residents #56 and #63 received medications in a timely manner. Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident Orders dated 12/31/2019 - 1/29/2020 and Medications Administration History dated 1/1/2020 - 1/28/2020 revealed Resident #72 was ordered: *Admelog [MEDICATION NAME] U-100 insulin pen (a medication to regulate the blood sugar level) sliding scale (number of units administered based on the blood sugar reading) before meals and at bedtime at 8:30 AM, 12:30 PM, 4:30 PM, and 8:00 PM. *Brilinta (prevents platelets from sticking together and forming clots) twice a day at 9:00 AM and 9:00 PM. *[MEDICATION NAME] (blood thinner) once a day at 9:00 AM for 21 days. *Glimepiride (medication to treat high blood sugar) once a day at 9:00 AM. Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed Admelog [MEDICATION NAME] U-100 insulin was documented administered late as follows: * 1/3/2020 at 9:13 PM (13 minutes late) patient care * 1/8/2020 at 2:08 PM (38 minutes late) patient care * 1/13/2020 at 11:15 AM (1 hour and 45 minutes late) patient care * 1/15/2020 at 10:04 AM (34 minutes late) patient care * 1/23/2020 at 2:14 PM (44 minutes late) patient care * 1/24/2020 at 6:27 PM (57 minutes late) patient care Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed Brilinta was documented administered late as follows: *1/2/2020 at 11:05 AM (1 hour and 5 minutes late) patient care *1/8/2020 at 10:52 PM (52 minutes late) patient care *1/17/2020 at 10:12 AM (12 minutes late) resident unavailable Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed [MEDICATION NAME] was documented administered late as follows: * 1/2/2020 at 11:05 AM (1 hours and 5 minutes late) patient care *1/17/2020 at 10:12 AM (12 minutes late) resident unavailable Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed Glimepiride was documented administered late as follows: *1/2/2020 at 11:05 AM (1 hours and 5 minutes late) patient care *1/17/2020 at 10:12 AM (12 minutes late) resident unavailable During an interview on 1/29/2020 at 8:10 PM, Licensed Practical Nurse (LPN) #2 stated sometimes medications were given late and it was documented on the Medication Administration History. When patient care was documented, it could mean the resident was being toileted, put to bed, etc., and .this can cause giving meds (medications) to take a while . During an interview on 1/30/2020 at 9:20 AM, LPN #1 stated nurses had one hour before and one hour after a medication was due to administer the medication timely. .The reasons meds are given late is situational. The residents move around; they go to dining, go to therapy . LPN #1 confirmed if the Medication Administration History read resident unavailable it meant the resident wasn't able to be located by the nurse and received the medication late. During an interview on 1/30/2020 at 9:45 AM, RN #1 stated the expectation was for medications to be administered 1 hour before or 1 hour after the scheduled time and the charted administration time was the time the medication was given. During review of RN #1's documentation on Resident #72's (MONTH) Medication Administration History, RN #1 stated .it is what it looks like (medications were charted as given late) . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Orders dated 1/9/2020 - 1/29/2020 showed Resident #3 was ordered the following: *[MEDICATION NAME] Sodium Gel ([MEDICATION NAME] Gel) 1% topical four times a day 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM *[MEDICATION NAME] (Antidepressant) capsule 80 mg once a day 9:00 AM *[MEDICATION NAME] (Mucus thinning agent) 400 mg four times a day 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM *[MEDICATION NAME] (antipsychotic) 2 mg at bedtime 9:00 PM Review of Resident #3's Medication Administration History dated 1/9/2020 - 1/29/2020 showed [MEDICATION NAME] Sodium Gel 1% was documented administered late as follows: * 1/11/2020 at 10:53 AM (53 minutes late) resident was unavailable. * 1/11/2020 at 6:14 PM (14 minutes late) resident was unavailable. * 1/12/2020 at 6:37 PM (37 minutes late) resident was unavailable. * 1/15/2020 at 12:13 PM (2 hours, 13 minutes late) resident was unavailable. * 1/15/2020 at 6:48 PM (48 minutes late) resident was unavailable. * 1/15/2020 at 10:28 PM (28 minutes late) patient care * 1/16/2020 at 11:14 AM (1 hour, 14 minutes late) resident was unavailable. * 1/16/2020 at 6:34 PM (34 minutes late) resident was unavailable. * 1/16/2020 at 10:30 PM (30 minutes late) patient care. * 1/17/2020 at 2:35 PM (35 minutes late) resident was unavailable. * 1/17/2020 at 6:30 PM (30 minutes late) resident was unavailable. * 1/18/2020 at 12:43 AM (2 hour, 43 minutes late) patient care. * 1/19/2020 at 10:37 PM (37 minutes late) charted late. * 1/20/2020 at 10:20 PM (37 minutes late) charted late. * 1/21/2020 at 2:32 PM (32 minutes late) administered late * 1/22/2020 at 10:17 AM (17 minutes late) patient care * 1/25/2020 at 3:37 PM (1 hour, 37 minutes late) resident was unavailable. * 1/26/2020 at 2:44 PM (44 minutes late) resident was unavailable. * 1/26/2020 at 6:51 PM (51 minutes late) resident was unavailable. * 1/26/2020 at 10:13 PM (13 minutes late) patient care. [MEDICATION NAME] 80 mg was documented administered late as follows: * 1/11/2020 at 10:53 AM (53 minutes late) resident was unavailable. * 1/15/2020 at 12:13 PM (2 hours, 13 minutes late) resident was unavailable. * 1/16/2020 at 11:14 AM (1 hour, 14 minutes late) resident was unavailable. * 1/22/2020 at 10:17 AM (17 minutes late) patient care. [MEDICATION NAME] 400 mg tablet was documented administered late as follows: * 1/21/2020 at 2:32 PM (32 minutes late) administered late. * 1/22/2020 at 10:17 AM (17 minutes late) patient care. * 1/25/2020 at 3:37 PM (1 hour 37 minutes late) resident was unavailable. * 1/25/2020 at 6:54 PM (54 minutes late) resident was unavailable. * 1/26/2020 at 2:44 PM (44 minutes late) resident was unavailable. * 1/26/2020 at 6:51 PM (51 minutes late) resident was unavailable. * 1/26/2020 at 10:13 PM (13 minutes late) patient care. [MEDICATION NAME] 2 mg tablet was documented administered late as follows: * 1/15/2020 at 10:28 PM (28 minutes late) patient care. * 1/16/2020 at 10:30 PM (30 minutes late) patient care. * 1/17/2020 at 12:43 AM (2 hours, 43 minutes late) patient care. * 1/20/2020 at 10:20 PM (20 minutes late) charted late. * 1/26/2020 at 10:13 PM (13 minutes late) patient care. During an interview conducted on 1/29/2020 at 4:50 PM, RN #1 stated .Resident may have been in therapy when documentation showed resident unavailable .I do the best I can to get to residents for medication pass .medications are to be administered 1 hour before or 1 hour after scheduled time . During an interview conducted on 1/30/2020 at 9:05 AM, RN #1 confirmed the medications for Resident #3 on the (MONTH) electronic Medication Administration Record [REDACTED]. That's why I documented them (the medications) that way .they were given late . Resident #349 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's Orders dated 1/28/2020 - 1/29/2020 showed Resident #349 was ordered the following: [MEDICATION NAME] 5 mg once a day at 8:00 AM [MEDICATION NAME] (iron supplement) 325 mg twice a day at 8:00 AM and 8:00 PM [MEDICATION NAME] (nerve pain medication) 300 mg twice a day at 8:00 AM and 8:00 PM [MEDICATION NAME] 600 mg twice a day at 8:00 AM and 8:00 PM [MEDICATION NAME] (high blood pressure medication) 20 mg once a day at 8:00 AM [MEDICATION NAME] (high blood pressure medication) 25 mg twice a day at 8:00 AM and 8:00 PM [MEDICATION NAME] (pain medication) 30 mg twice a day at 8:00 AM and 8:00 PM Review of the Medication Administration History dated 1/1/2020 - 1/29/2020 showed Resident #349's medications were documented as administered late as follows: *[MEDICATION NAME] 5 mg on 1/27/2020 at 9:19 AM (19 minutes late) patient just returned from breakfast. *[MEDICATION NAME] 325 mg on 1/27/2020 at 9:19 AM (19 minutes late) patient just returned from breakfast. *[MEDICATION NAME] 300 mg and [MEDICATION NAME] 600 mg (total dose of 900 mg) on 1/27/2020 at 9:22 AM (22 minutes late) patient just returned from breakfast. *[MEDICATION NAME] 20 mg on 1/27/2020 at 9:19 AM (19 minutes late) patient just returned from breakfast. *[MEDICATION NAME] 25 mg on 1/27/2020 at 9:27 AM (27 minutes late) patient just returned from breakfast. *[MEDICATION NAME] mg on 1/27/2020 at 9:24 AM (24 minutes late) patient just returned from breakfast. During an interview conducted on 1/30/2020 at 9:45 AM, RN #5 confirmed that medications were to be given one hour before or one hour after the scheduled time and the medications for Resident #349 were administered late. Resident #191 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Orders dated 1/28/2020 - 1/29/2020 showed Resident #191 was ordered the following: *[MEDICATION NAME] 12.5 mg twice a day 9:00 AM and 9:00 PM. Review of Resident #191's Medication Administration History dated 1/1/2020 - 1/29/2020 showed [MEDICATION NAME] was documented administered late as follows: *1/28/2020 at 10:24 AM (1 hour and 24 minutes late) resident unavailable. During an interview conducted on 1/29/2020 at 4:55 PM, LPN #3 confirmed that if a medication was scheduled for 9:00 AM, administration time could range from 8:00 AM (1 hour before) to 10:00 AM (1 hour after). During an interview conducted on 1/29/20 at 5:00 PM, RN #2 confirmed medications could be administered 1 hour before or 1 hour after the scheduled time. During an interview conducted on 1/29/2020 at 9:30 PM, the DON confirmed that the medications were documented as given late and the administration times did not comply with the facility's medication administration policy. During an interview conducted on 1/29/2020 at 7:00 PM, the Consultant Pharmacist stated during monthly chart reviews, a trend was noted for with 8AM and 9 AM scheduled medications being administered late. This trend was discussed with the Director of Nursing and the Medical Director at the quarterly medication error meeting. The standard of practice was to administer medications within a 1 hour window before or after the scheduled time a medication was due. During an interview on 1/30/2020 at 10:21 AM, the Medical Director stated the expectation was for nurses to administer medications within 1 hour before or 1 hour after the scheduled time.

Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 resident (#366) of 3 residents reviewed for accidents, of 23 sampled residents. The findings included: Medical record review revealed Resident #366 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 5 Day Scheduled assessment dated [DATE], revealed Resident #366 required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers. Medical record review of Resident #366's Completed Care Plan dated 8/30/17, revealed, . Safety/Potential for falls .Goal .desires to be safe and will have no falls .inability to perform all ADL tasks without staff assistance .assist with ADLs .limited in .functional transfers .assist patient with mobility/transfers . Medical Record review of the MDS Unscheduled assessment dated [DATE], revealed Resident #366 required extensive assistance with ADLs and 2 person physical assist for transfers. Medical record Review of the POS [REDACTED].transfer from recliner to wheelchair and patient was facing recliner with wheelchair behind her when patients knees seemed to buckle. Patient's legs gave out and patient started going down .gently lower patient to knees on the floor . Continued review revealed, .immediate interventions .2 person assist for all transfers . Medical Record review of the Daily Skilled Nursing Notes dated 9/30/17 at 10:00 PM, revealed, .fall/let down to floor .(no) injuries noted .new intervention to have assist (2 person) for all transfers . Interview with Registered Nurse #1 on 10/24/17 at 3:55 PM, in the conference room, confirmed the MDS assessment was accurate and the resident required 2 persons for transfers. Interview with the Director of Nursing on 10/24/17 at 4:39 PM, in the conference room, confirmed, .it (MDS) should match (the care plan) .we need to be able to follow the care plan . Continued interview confirmed the facility failed to develop a comprehensive care plan that addressed the functional transfer needs for Resident #366, based on the comprehensive MDS assessment.

Based on review of facility policy, medical record review, review of facility investigations, and interview, the facility failed to implement individualized care plan interventions to prevent falls for 6 residents (#1, #3, #2, #5, #7, and #9) of 10 residents reviewed for falls. Resident #1 sustained a fractured wrist and [MEDICAL CONDITION] requiring sutures and Resident #3 sustained a [MEDICAL CONDITION]. The facility's failure to implement individualized care plans for falls placed Residents #1 and #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Assistant Administrator, Assistant Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, and the Health Information/Quality Assurance Quality Improvement Coordinator were notified of the Immediate Jeopardy on 6/19/17 at 2:40 PM, in the conference room. The findings included: Review of the facility policy Assessing Falls and Their Causes revised 10/2010, revealed .Review the resident's care plan to assess for any special needs of the resident . Review of the facility policy Falls-Clinical Protocol last revised 9/2012, revealed .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Interim Care Plan (ICP) dated 5/8/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment; Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad on: Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions .WC (Wheelchair) seating assessment/WC seat cushion/Adaptive equipment . Medical record review of the Falls Risk Assessment and document dated 5/8/17 revealed .Total score of 10-13 represents High Risk. Total score of 14 or more represents Severe Risk . Continued review revealed Resident #1 scored a 23 (severe risk). Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident had short term memory problems and had moderate impairment of cognitive skills for daily decision making. Continued review revealed the resident required extensive assist for transfers, dressing, and personal hygiene with 1 person assist. Further review revealed the resident had a fall with a fracture in the past month (prior to admission). Medical record review of the facility's Post Falls Nursing assessment dated [DATE] at 1:20 PM, revealed .found in her room on the floor next to her bed on the right side with her feet facing the bed and her head toward the door. Patient had a laceration on her head above her left eye near her eye brow .Safety devices in use .Alarm .Patient was wearing following devices: Footwear/nonskid socks .What immediate interventions were initiated to prevent future falls? .Clear walking pathway . Review of the facility's Post Falls Investigation dated 5/20/17 revealed Resident #1 had an alarm in place and it was not sounding. Continued review revealed .Needed care plan changes: Nonskid socks added to help pt (patient), clear walking path . (Investigation indicated resident was wearing nonskid socks at the time of the fall.) Medical record review revealed the ICP was updated on 5/20/17 with handwritten [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #3 on 6/8/17 at 10:40 AM, on the second floor hallway, revealed .the alarm on the wheelchair was not sounding .it was unplugged .she (Resident #1) would not have unplugged it and it couldn't have been disconnected by pulling on it (cord) . Continued interview confirmed the resident was wearing nonskid socks at the time of the fall. Telephone interview with Occupational Therapist (OT) #2 on 6/8/17 at 11:50 AM revealed .I returned her (Resident #1) to her room .I did notice during therapy when she stood up the alarm did not sound .no did not report it (alarm not working) to the nurse . Interview with the Director of Nursing (DON) on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting (falls intervention listed on the ICP) .staff makes rounds if observe someone is restless will take them to the bathroom . Interview with the Risk Manager (RM) on 6/12/17 at 3:00 PM, in the conference room, confirmed the care plan interventions of non-skid socks and clear pathways were not appropriate interventions after Resident #1's fall. Interview with the Director of Nursing (DON) on 6/19/17 at 2:00 PM, in the conference room, confirmed the facility failed to ensure the alarm was in place as care planned. In summary, Resident #1 was admitted to the facility for rehabilitation therapy after having a fall at home resulting in a [MEDICAL CONDITION] and surgical repair. The resident was identified as at a severe risk for falls upon admission 5/8/17. The facility had care planned safety interventions of scheduled toileting and pressure pad alarms to the bed and wheelchair. The facility did not implement scheduled toileting, even though it was an intervention on the care plan. On 5/20/17 the resident was assisted by the therapist back to her room after therapy. Interview with the therapist confirmed she was aware the alarm was not functioning and she failed to report it to the nurse. Because the facility failed to follow the ICP, the Resident was found lying on the floor on her stomach with a laceration to her left brow requiring sutures and a wrist fracture. After the fall on 5/20/17, the facility failed to implement a care plan with appropriate interventions to prevent additional falls. Medical record review revealed Resident #3 was admitted to the facility 5/18/17 with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing Assessment Report dated 5/18/17 revealed the resident was alert and confused. Continued review revealed the resident required extensive assist for transfers with 2 person assist. Medical record review of the ICP for Resident #3 dated 5/18/17 revealed .Problem: Falls Risk/Potential for injury .Interventions .Fall Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad on Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions . Medical record review of the Falls Risk assessment dated [DATE] revealed Resident #3 scored a 21 (severe risk). Medical record review of a nurse's note dated 5/22/17 revealed .20:35 (8:35 PM) Resident has set off bed alarm twice this shift (7 PM/7 AM) getting out of bed. No sitter present. Nurse contacted daughter .inquired where is sitter .Nurse told daughter the resident has gotten out of bed unassisted twice .setting off alarms . Medical record review of a nurse's note dated 5/22/17 revealed .20:45 (8:45 PM) staff heard bed alarm sounding and found resident lying on floor at foot of her bed on her back. Nurse elicited significant pain response with minimal range of motion to left hip . Review of a facility's fall investigation dated 5/22/17 at 8:45 PM revealed the resident fell and was sent to the hospital for evaluation of hip pain. Medical record review of the hospital History and Physical dated 5/23/17 revealed the resident was admitted to the hospital with [REDACTED]. Medical record review of the ICP updated 5/23/17 revealed the handwritten intervention .Add clip alarm . Medical record review of the 5-day MDS assessment dated [DATE] revealed Resident #3 had severely impaired cognition, required extensive assistance of two persons for transfers, toileting, and hygiene, and had a history of [REDACTED]. Interview with the RM on 6/8/17 at 11:30, in the conference room, revealed Resident #3 .previously had a sitter (family provided) .she was trying to climb out bed .we don't provide one to one (1:1) care . Telephone interview with RN #5 on 6/8/17 at 12:20 PM revealed .we just continued to listen for her (Resident #3) alarm and when we would hear it we would go back in there .I was hoping it would make her daughter think she really does need a sitter when I called her and told her she had gotten out of bed twice already .what else could we have done . Interview with the DON on 6/12/17 at 8:45 AM, in the conference room revealed .don't have scheduled toileting (intervention listed on the care plan) . Interview with the DON on 6/19/17 at 2:00 PM, in the conference room, revealed .I think he (RN #5) had good intentions .there was not enough time for him to implement a new intervention . Interview with the Assistant Regional Director of Clinical Services on 6/19/17 at 2:05 PM, in the conference room, revealed .if they (residents) require one to one supervision would consider them inappropriate for our facility . In summary, the facility was aware of Resident #3's risk for falls and the resident's attempts to get out of bed. The facility did not implement scheduled toileting, as care planned, and the RN expectations were the family would provide a sitter for the resident, although not care planned. The facility failed to implement care plan interventions, based on the resident's behaviors, to prevent a fall, resulting in a [MEDICAL CONDITION]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was discharged from the facility to an Assisted Living Facility (ALF) on 6/8/17. Medical record review of the ICP dated 5/11/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Clip alarm .Assist with mobility between therapy sessions . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored an 18 (severe risk). Medical record review of the 5 Day MDS dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 7 (severe impairment). Continued review revealed the resident required extensive assist for transfers, dressing and personal hygiene with 1-2 person assist. Further review revealed the resident had 1 fall in the last month (prior to admission to the facility). Review of the facility investigations revealed the resident had 3 falls on 5/19/17, 5/24/17, and 6/2/17, without injuries. Review of the facility's Post Falls Investigation dated 5/19/17 revealed .Interventions: Teach PT (patient) to rise slowly from sitting position . Medical record review of the ICP revealed this intervention was not on the ICP. Review of the POS [REDACTED].Needed care plan changes: Walking assessment and or wheelchair assessment . Medical record review of the ICP revealed this intervention was not on the ICP. Medical record review of the ICP revealed the care plan was updated with handwritten interventions, and no dates for the revisions, .keep pt (patient) in high traffic areas .nonskid socks or shoes .Make sure alarm functioning properly . Medical record review of Resident #2's Complete Patient Care Plan dated 5/31/17, revealed, .Instruct patient to call for assistance with mobility, transfers and other needs .Patient requires verbal cueing for recall and reminders .Keep call light and often used items within easy reach .Instruct patient on safety issues including use of call light, proper foot wear and to keep environment uncluttered .Pressure pad alarms in bed and W/C (wheel chair); check batteries q (every) shift and replace batteries as needed . Review of a facility Post Falls Nursing assessment dated [DATE] revealed .safety devices in use: Alarm . Review of a facility Post Falls Investigation dated 6/2/17 revealed .Educated pt (patient) to use call light before getting up and if needs assistance . Review of the care plan updated 6/2/17, revealed a handwritten intervention .educate patient on proper use of call light and to call for assistance w/ (with) mobility and transfers-Ask pt (patient) to demonstrate back correct use of call light and reasons why they should use the call light . (This intervention was already in place on the ICP since 5/11/17.) Interview with Physical Therapist #1 on 6/8/17 at 12:15 PM, in the conference room, revealed .Do not have a walking assessment or wheelchair assessment that we complete .that is just something we look at every day when working with a resident . Interview with the RM on 6/12/17 at 3:00 PM, in the conference room, revealed .nurse suggested that as an intervention .was not aware it was something they (therapist) do every day . Interview with the Assistant Director of Nursing (ADON) on 6/15/17 at 10:20 AM, in the conference room, confirmed the care plan interventions of education to rise slowly when standing and to use the call light before getting up were not appropriate interventions for the resident. In summary, Resident #2 had a BIMS score of 7. Fall interventions of resident education and use of a call light were not appropriate due to the resident's cognition. The intervention of a walking and/or wheelchair assessment was not an appropriate falls intervention since they were a routine assessment being conducted by therapy. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 discharged from the facility to an ALF on 6/13/17. Medical record review of the Admission Nursing Assessment Report dated 5/23/17 revealed the resident was oriented to self only. Continued review revealed the resident required extensive assist with transfers and 2 person assist. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 17 (severe risk). Medical record review of the ICP dated 5/24/17 revealed .Problem Falls Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad Bed Wheelchair .Scheduled Toileting Program .Assist with mobility between therapy sessions . Review of a facility investigation dated 5/25/17 revealed Resident #5 had attempted to stand from his wheelchair, lost his balance, and fell . Medical record review of a facility Post Falls Nursing assessment dated [DATE] revealed .Interventions: Medication Review by Pharmacist . Medical record review of the ICP updated 5/25/17 revealed the handwritten intervention . Pharmacist to review meds (medications) . Medical record review of the Consultant Pharmacist Patient Evaluation dated 5/30/17 revealed the medications were reviewed by the pharmacist and there were no recommendations for medication changes or adjustments. Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting (intervention on the ICP) . Interview with the DON on 6/19/17 at 9:00 AM, in the conference room, confirmed no medication changes were made and no additional interventions were implemented on the care plan. In summary, Resident #5 fell on [DATE] with the care plan updated to include a pharmacist medication review after the fall. The medications were reviewed by the pharmacist with no changes made. The facility failed to re-evaluate and implement care plan interventions to prevent falls after it was determined the medications had not contributed to the fall. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 19 (severe risk). Medical record review of the ICP dated 3/3/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions .WC (wheelchair) seating assessment/WC seat cushion/Adaptive equipment .Activities . Medical record review of the 5 Day MDS dated [DATE] revealed the resident had short-term memory problem and moderate impaired cognition. Continued review revealed the resident required extensive assistance for transfers, dressing, and bathing with 1-2 person assist. Review of facility investigations revealed Resident #7 had 4 falls (3/9/17, 3/10/17, 3/13/17, and 3/15/17). Review of the facility's Post Falls Investigation dated 3/9/17 revealed .Someone needs to be with the patient while he is toileting . Medical record review of the ICP revealed these interventions were not implemented on the care plan. Medical record Review of the POS [REDACTED].was found sitting on the floor beside the bed .stated he needed to go to the bathroom .Intervention: Re-educated PT (patient) on the use of the call light and importance of calling for assistance . Review of the facility's Post Falls Investigation dated 3/10/17 revealed .Patient needs not to be left unattended while toileting . Medical record review of the ICP updated 3/10/17 revealed the handwritten intervention .reeducated the PT (patient) on proper use of call light and importance of calling for assistance . The intervention of instruct resident and family to call for assist with mobility/transfers was initiated on 3/3/17. Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting .(intervention implemented on the ICP) . Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, revealed .we can try to re-educate in hopes that something takes .but not appropriate as an intervention .should have done something else . Continued interview revealed .I think attend while toileting was for a different fall . Further interview confirmed the facility failed to implement appropriate care plan interventions post fall for Resident #7 on 3/10/17. In summary, Resident #7 had moderate cognitive impairment. The facility failed to implement the new intervention to not be left unattended while toileting on the ICP. The intervention of re-education to use the call light was not an appropriate intervention for this resident. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 discharged from the facility to ALF on 5/1/17. Medical record review of the Admission Nursing Assessment Report dated 3/20/17 revealed the resident was alert and oriented with occasional confusion/forgetfulness. Continued review revealed the resident required extensive assist with transfers with 2 person assist. Medical record review of the ICP dated 3/20/17 revealed .Problem: Falls Risk/Potential for injury .Interventions .Fall Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Provide reminders and cues regarding safety as need .Alarm pressure pad Bed Wheelchair . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 16 (severe risk). Review of facility investigations revealed Resident #9 had 4 falls (3/23/17, 3/25/17, 4/18/17, and 4/24/17). Medical record review of the ICP updated 3/23/17 revealed the handwritten intervention .scheduled toileting . Review of a Post Falls Investigation dated 3/25/17 revealed .scheduled toileting . Medical record review of the ICP revealed no new care plan interventions were implemented after the 3/25/17 fall. Medical record review of the 5 day MDS dated [DATE] revealed the resident scored a 10 (moderate impairment) on the BIMS. Continued review revealed the resident required extensive assist with transfers, dressing, and personal hygiene with 1 person assist. Further review revealed the resident had a fall history prior to admission and had 2 falls since admission to the facility. Medical record review of the Complete Patient Care Plan dated 4/7/17, revealed, .At increased risk for falls r/t (related to) history of falls and Subdural Hemorrhage .Instruct patient to call for assistance with mobility, transfers, and other needs .Keep call light and often used items within easy reach .Instruct patient on safety issues including use of call light, proper foot wear and to keep environment uncluttered .Obtain standing blood pressure daily .Pressure pad alarms in bed and W/C; check batteries q shift and replace batteries as needed . Medical record review of a Post Falls Nursing assessment dated [DATE] revealed .fall mat . Medical record review of the ICP updated 4/18/17 revealed the handwritten intervention .fall mats . Medical record Review of the POS [REDACTED].staff heard pressure alarm sounding. Resident found on knees on floor beside his bed .fell from bed to go to bathroom .Skin tear to left knee .Safety devices in use: Alarm .Immediate intervention bed tab alarm (type of personal safety alarm) . Review of the facility's Post Falls Investigation dated 4/24/17 revealed . Apply tab alarm to patient . Medical record review of the ICP updated 4/24/17 revealed .tab alarm to bed and wheelchair . Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting .(intervention implemented on the ICP) . Telephone interview with Licensed Practical Nurse (LPN) #7 on 6/15/17 at 9:30 AM, revealed .the alarm was not sounding (at the time of the fall on 4/24/17) .we pressed on it and it didn't sound .we replaced it .had worked at beginning of shift .I don't know if we put it (fall mat) there that night or if they did it the next day .let the supervisor take care of that .Do not remember ever seeing a mat in his room before he discharged (5/1/17) . Telephone Interview with RN #5 on 6/15/17 at 1:40 PM revealed .don't recall if the fall mat was at bedside or not . Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, confirmed no new intervention was implemented post fall 3/25/17 and the Post Falls Investigation for 4/24/17 did not indicate if the fall mat was in place as care planned. In summary, Resident #9 fell on [DATE] with the intervention of scheduled toileting added to the ICP, but scheduled toileting was not implemented; on 3/25/17 no new care plan interventions were added post fall; and on 4/18/17 the ICP was updated with the intervention of a fall mat. However, there was no evidence to support the fall mat had been placed at the bedside, at the time of the fall on 4/24/17, as care planned on 4/18/17. The Immediate Jeopardy was effective 5/20/17 through 6/20/17. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy, was received on 6/20/17. The corrective actions were validated on site through review of documents, observations, and staff interviews by the surveyor on 6/20/17. 1. The Administrator, Physician, Director of Nursing, Assistant Director of Nursing, Risk Manager, Maintenance Director, Social Worker, Activities Director, Dietitian, Director of Rehabilitation, and a Certified Nurse Assistant reviewed and updated Resident #3's care plan with the intervention of a concave mattress. Resident #1 had discharged home on[DATE]. 2. Review of a facility document and interview with the DON on 6/20/17 confirmed the DON, ADON, Risk Manager, and Regional Nurses conducted a review of all residents and verified all safety devices were in place and functional as care planned. 3. Reviewed facility in-service records dated 6/19/17 and 6/20/17, and observations and interviews were conducted on 6/20/17 from 4:40 PM to 7:15 PM with 7 RNs, 2 LPNs, 4 CNAs, 2 Therapists, covering both shifts, and the DON, ADON, and the Risk Manager, to validate the nursing and therapy staff had been educated on the use of the alarms. Staff was in-serviced on ensuring interventions were in place, what to do if an alarm is not functioning and staff responsibility to implement additional interventions as needed based on resident needs. Staff received training on procedures for identifying orthostatic [MEDICAL CONDITION] and reporting concerns to the medical staff. Staff was in-serviced on a new electronic tool used to verify alarms and safety equipment are in use and working properly. The electronic tool can be updated 24/7 and is a communication tool between all disciplines. 4. Observations on 6/20/17 beginning at 5:15 PM confirmed the safety measures for 3 additional residents at risk for falls were listed on the Kardex located in the resident's inside door closet and the electronic communication tool was available with safety devices in use and measures had been implemented as assessed and care planned. 5. Review of the facility audit tool, medical record reviews, and observations revealed the facility had implemented evaluation and monitoring of safety interventions/devices, and updated care plans and the electronic communication tool by 6/20/17. The noncompliance continues at a scope and severity of D for monitoring of the effectiveness of collective actions to ensure sustained compliance. Refer to F-323

Based on review of facility policy, review of manufacturer's recommendations, medical record review, review of facility fall investigations, observations, and interviews, the facility failed to ensure safety devices were in place and functioning properly for 1 resident (#1), failed to provide adequate supervision to prevent falls for 1 resident (#3), and failed to ensure implementation of falls interventions based on facility investigation of causes of falls for 5 residents (#1, #2, #5, #7, and #9) of 10 residents reviewed for falls. Resident #1 sustained a fractured wrist and head laceration requiring sutures and Resident #3 sustained a fractured hip. The facility's failure to implement interventions to prevent falls placed Residents #1 and #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Assistant Administrator, Assistant Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, and the Health Information/Quality Assurance Quality Improvement Coordinator were notified of the Immediate Jeopardy on 6/19/17 at 2:40 PM, in the conference room. The facility was cited Substandard Quality of Care at F-323. The findings included: Review of the facility policy Falls and Fall Risk, Managing revised December 2007, revealed, .staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped .if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment .until falling is reduced or stopped .staff will monitor and document each resident's response to interventions .if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriated to continue or change interventions . Review of the facility policy Assessing Falls and Their Causes revised October 2010 revealed, .After an observed or probable fall, the staff will clarify the details of the fall .Within 24 hours of a fall, the nursing staff will begin to identify possible or likely causes of the incident .Staff will evaluate chains of events or circumstances preceding a recent fall .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls . Review of the Manufacturer's Recommendations for the facility's Pressure Pad Alarm, undated, revealed .plug the pad into the bottom of the monitor .place monitor out of reach of the resident. Suitable mounting locations include: back of headboard, back of wheelchair, wall or under the bed. Make sure the resident cannot tamper with monitor or reach the 'Reset' button .apply pressure to the pad to activate the sensor device. The monitor will beep twice .alarm will sound when pressure is removed from the pad .the 'in use' light will blink every 3 seconds to indicate pressure has been applied to the pad. When the alarm is activated press the Reset button. This will deactivate the alarm .apply pressure to the pad to reactivate the alarm . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Falls Risk assessment dated [DATE] revealed .Total score of 10-13 represents High Risk. Total score of 14 or more represents Severe Risk . Continued review revealed the resident scored a 23 (severe risk). Medical record review of the Interim Care Plan (ICP) dated 5/8/17 revealed .Problem: Fall Risk/Potential for injury .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad on: Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions .WC (Wheelchair) seating assessment/WC seat cushion/Adaptive equipment . Review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident had short term memory problems and had moderate impairment of cognitive skills. Continued review revealed the resident required extensive assist for transfers, dressing, and personal hygiene with 1 person assist. Further review revealed resident had a fall with a fracture in the past month (prior to admission). Medical record review of a facility's Post Falls Nursing assessment dated [DATE] at 1:20 PM revealed .found in her room on the floor next to her bed on the right side with her feet facing the bed and her head toward the door. Patient had a laceration on her head above her left eye near her eye brow .Safety devices in use .Alarm .Patient was wearing following devices: Footwear/nonskid socks .What immediate interventions were initiated to prevent future falls? .Clear walking pathways . Medical record review of a nurse's note dated 5/20/17 revealed .13:25 (1:25 PM) .EMS (emergency medical service) at bedside to transfer to (hospital) . Medical record review of the hospital Discharge Instructions dated 5/20/17 revealed .Diagnosis: [REDACTED].Lip Laceration . The resident's wrist was splinted and the head laceration required 6 sutures. Review of the facility's Post Falls Investigation dated 5/20/17 revealed Resident #1 had an alarm in place and it was not sounding. Continued review revealed .Needed care plan changes: Nonskid socks added to help pt (patient), clear walking path . Medical record review revealed Resident #1's ICP was updated 5/20/17 with a [DIAGNOSES REDACTED]. Medical record review of a physician progress notes [REDACTED].Pt (patient) was found in floor on 5/20 & (and) hit head & injured (L) (left) wrist .found to have (L) distal radius fx (fracture). Laceration to (L) eyebrow sutured .Now pt using considerably more Tramadol (pain medication) to prevent pain .(L) arm in splint . Medical record review of the Occupational Therapist (OT) Progress Note dated 5/22/17 revealed .Prior Level of Function 5/15/17 .The patient demonstrates standing balance of F- static (able to maintain static balance with UE (upper extremity) support) and holds for 7 minutes to complete self-care tasks .able to transfer to toilet/commode requiring minimal assistance (1-25%) due to increased fatigue with 25% verbal instruction/cues for proper body positioning and feet placements to enhance task .Current level of function .demonstrates standing balance of F-static and holds for 0 minutes due to fall over the weekend that resulted in a left wrist fracture and facial lacerations .able to transfer to toilet/commode requiring moderate/maximum assistance (76-99% assist) with initiation cue and 60% tactile and verbal instruction/cues for safety .STG (short term goals) have been extended to more accurately reflect patient's functional needs/requirements .may use platform walker (specialized walker for persons unable to grip regular walker handles) . Observation of Resident #1 on 6/7/17 at 11:45 AM, in her room, revealed the resident was seated in a wheelchair with steri-strips to her left forehead and a hard cast on her left arm. Continued observation revealed a pressure pad alarm was in place and the in use indicator light was flashing. Interview with OT #1 on 6/8/17 at 9:50 AM, in the therapy room, revealed .don't turn alarms off any more. I used to but I would sometimes forget to turn them back on so I just reset them now . Interview with Registered Nurse (RN) #3 on 6/8/17 at 10:40 AM, on the second floor hallway, revealed .her (Resident #1) daughter normally stays with her .she had left after the therapist took the resident (to the therapy room) .saw (Resident #1) coming down the hallway with the therapist .reminded her where her daughter was and that she would return shortly .entered room across the hall and as I was coming back out (Certified Nurse Assistant (CNA) #5) called my name .she (Resident #1) was lying on the floor in the prone position with a gash to her left brow . Continued interview with RN #3 revealed the resident was sent to the hospital for evaluation of her left wrist pain and treatment for [REDACTED]. Further interview revealed .the alarm on the wheelchair was not sounding .it was unplugged .she (Resident) #1 would not have unplugged it and it couldn't have been disconnected by pulling on it (cord) .can't say for sure who unplugged it . Continued interview confirmed the resident was wearing nonskid socks at the time of the fall. Interview with Certified Nurse Assistant (CNA) #5 on 6/8/17 at 11:00 AM, in the second floor living area, revealed .had taken a resident downstairs .came back down the hall and I could see the top of her (Resident #1) head sticking out of the door .alarm was not sounding . Continued interview revealed .called for the nurse .assisted (Resident #1) back to bed .then checked the alarm .it was just dangling unplugged .still had same alarm .I don't know who had unplugged it . Observation and interview with RN #3, CNA #5, and Resident #1's daughter on 6/8/17 at 11:10 AM, in the resident's room, revealed Resident #1 was seated in her wheelchair, the alarm box was attached to the wheel chair handle with a strap, and the alarm box and pressure pad cord were connected with the in use indicator light blinking. Continued observation revealed RN #3 demonstrated pulling on the cord of the pressure pad and was unsuccessful in separating the alarm box and cord. Further observation revealed the pad cord alarm connector had to be manually depressed by the RN before it could be disconnected from the alarm box. Interview with Resident #1's daughter revealed Resident #1 .has had to stay longer (in the facility) than we were first told because of the fall .set her back .had to get a different walker for her to use to prop her arm up . Telephone interview with OT #2 on 6/8/17 at 11:50 AM revealed .I returned her (Resident #1) to her room .I did notice during therapy when she stood up the alarm did not sound .not aware of a standard procedure for trouble shooting when an alarm isn't working .I know I reviewed her call light use before I left her .no did not report it (alarm not working) to the nurse. It was not uncommon for people to come to therapy and the alarm not sound .it just slipped my mind . Interview with the Risk Manager (RM) on 6/12/17 at 3:00 PM, in the conference room, confirmed the care plan interventions of non-skid socks and clear pathways were not appropriate interventions based on the cause of Resident #1's fall. Interview with the Therapy Rehabilitation Manager on 6/15/17 at 12:40 PM, in her office, revealed .no official (training) to show them (therapist) how they (alarms) work. Basically you return them (residents) the way you found them .if alarm is off when they come they (residents) are returned that way . Interview with the Director of Nursing (DON) on 6/19/17 at 2:00 PM, in the conference room, confirmed the facility failed to ensure the alarm was functioning properly. Continued interview revealed .Alarms will alert you if a person is getting up .It's an alerting system with a safety feature so is an intervention but it is not fool proof . In summary, Resident #1 was admitted to the facility for rehabilitation therapy after a fall with a fractured hip requiring surgical repair, with the goal to return home with her husband. The resident was identified as a severe risk for falls upon admission 5/8/17. The facility had care planned safety interventions, including the use of pressure pad alarms to the bed and wheelchair. On 5/20/17 the resident was assisted by the therapist back to her room after therapy. OT #2 confirmed she was aware the alarm was not functioning, did not know how to fix it, and failed to report it to the nurse. Resident #1 was found on the floor and sustained a left wrist fracture and a laceration to her left brow requiring 6 sutures. Interviews confirmed the chair pressure pad alarm was unplugged and did not alarm. The falls investigation and interventions implemented did not address the alarm being disconnected and new interventions of nonskid socks, which the resident was already wearing at the time of the fall, and clear pathways were not based on an investigation of the cause of the fall. Resident #3 was admitted to the facility 5/18/17 with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing Assessment Report dated 5/18/17 revealed the resident was alert and confused. Continued review revealed the resident required extensive assist for transfers with 2 person assist. Medical record review of the ICP for Resident #3 dated 5/18/17 revealed .Problem : Falls Risk/Potential for injury .Interventions .Fall Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad on Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 21 (severe risk). Medical record review of a physician's order dated 5/20/17 revealed Seroquel (antipsychotic medication) 12.5 mg (milligrams) po (by mouth) q (every) 0600 (6:00 AM) .Seroquel 25 mg po q 8:00PM . Medical record review of a physician progress notes [REDACTED].behaviors no better .new Seroquel orders 12.5 mg po at 4:00 AM, 12.5 mg po at 3:00 PM, 25 mg po at 9:00 PM . Medical record review of a nurse's note dated 5/22/17 revealed .20:35 (8:35 PM) Resident has set off bed alarm twice this shift (7 PM to 7 AM) getting out of bed. No sitter present. Nurse contacted daughter .inquired where is sitter. Daughter stated resident's meds (medications) were adjusted and resident no longer needs sitter. Nurse told daughter resident has gotten out of bed unassisted twice this shift setting off alarms . Medical record review of a nurse's note dated 5/22/17 revealed 20:45 (8:45 PM) staff heard bed alarm sounding and found resident lying on floor at foot of her bed on her back. Nurse elicited significant pain response with minimal range of motion to left hip . Review of a facility's fall investigation revealed the resident had a fall on 5/22/17 at 8:45 PM, and was sent to the hospital for evaluation of hip pain. Medical record review of the hospital history and physical dated 5/23/17 revealed the resident was admitted to the hospital and diagnosed with [REDACTED]. The resident was discharged on [DATE] and readmitted to the facility. Medical record review revealed of the ICP dated 5/23/17 revealed use of a clip alarm (a personal safety alarm) was implemented. Medical record review of the 5-day MDS assessment dated [DATE] revealed Resident #3 had severely impaired cognition, required extensive assistance of two persons for transfers, toileting, and hygiene, and had a history of [REDACTED]. Review of the facility floor plan revealed Resident #3's room was located 3 rooms down the hall from the nurse's station. Interview with CNA #4 on 6/7/17 at 3:00 PM, in the hallway, revealed Resident #3 .is alert, aggressive, violent, will spit and bite .has a sitter (family provided) 24 hours a day . Observation with RN #3 on 6/8/17 at 11:00 AM, outside of Resident #3's room, revealed the nurse instructed a visitor it was probably not a good time to visit the resident. Interview with RN #3 on 6/8/17 at 11:05 AM, outside of Resident #3's room, revealed .she (Resident #3) is very agitated. I was just about to give her something to help calm her down . Interview with the Risk Manager on 6/8/17 at 11:30 AM, in the conference room, revealed Resident #3 .previously (before the fall) had a sitter (family provided) .she was trying to climb out bed .we don't provide one to one care . Telephone interview with RN #5 on 6/8/17 at 12:20 PM, revealed on the night the resident fell , .we just continued to listen for her (Resident #3) alarm and when we would hear it we would go back in there .I was hoping it would make her daughter think she really does need a sitter when I called her and told her she had gotten out of bed twice already .what else could we have done . Interview with the DON on 6/19/17 at 2:00 PM, in the conference room, revealed I think he (RN #5) had good intentions .there was not enough time for him to implement a new intervention (in reference to time between resident setting off alarms and RN leaving resident unattended to call the daughter) . Interview with the Assistant Regional Director of Clinical Services on 6/19/17 at 2:05 PM, in the conference room, revealed .if they (residents) require 1:1 supervision would consider them inappropriate for our facility . In summary, Resident #3 was admitted to the facility for rehabilitation therapy with the goal of returning to her previous assisted living setting. The resident was identified as severe risk for falls upon admission to the facility. The nurse contacted the family and reported the resident had gotten out of bed twice during the shift setting off alarms. The resident was assisted back to bed by the nurse without additional interventions, and left unattended. The resident got up a third time, fell , and sustained a fractured hip. The resident was admitted to the hospital, underwent a left hip hemiarthroplasty, returned to the facility on [DATE], and remained in the facility. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was discharged from the facility to an Assisted Living Facility (ALF) on 6/8/17. Medical record review of the ICP dated 5/11/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Clip alarm .Assist with mobility between therapy sessions . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored an 18 (severe risk). Medical record review of the 5 Day MDS dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 7 (severe impairment). Continued review revealed the resident required extensive assist for transfers, dressing and personal hygiene with 1-2 person assist. Further review revealed the resident had 1 fall in the last month (prior to admission to the facility). Medical record review of the facility Post Falls Nursing assessment dated [DATE] at 6:30 PM, revealed .PT (patient) found lying on the floor, states she was trying to sit in wheelchair . Further review revealed the resident had no injuries. Review of the facility Post Falls Investigation dated 5/19/17 revealed, .Interventions: Teach PT (patient) to rise slowly from sitting position . Medical record review of the Post Falls Nursing assessment dated [DATE] at 12:50 PM revealed, .night shift CNA went into pt room and observed pt on batroom (bathroom) on floor on back with arms at side . and the resident had no injuries. Review of the facility Post Falls Investigation dated 5/24/17 at 12:50 PM, revealed .Walking assessment or wheelchair assessment . Medical record review of the ICP revealed hand written updates, with no dates, .keep pt (patient) in high traffic areas .nonskid socks or shoes .Make sure alarm functioning properly . Medical record review of Resident #2's Complete Patient Care Plan dated 5/31/17, revealed, .Instruct patient to call for assistance with mobility, transfers and other needs .Patient requires verbal cueing for recall and reminders .Keep call light and often used items within easy reach .Instruct patient on safety issues including use of call light, proper foot wear and to keep environment uncluttered .Pressure pad alarms in bed and W/C (wheel chair); check batteries q (every) shift and replace batteries as needed . Review of a facility Post Falls Nursing assessment dated [DATE] revealed .Patient was found on the floor by CNA .safety devices in use: Alarm . Review of a facility Post Falls Investigation dated 6/2/17 revealed Alarm .in place .Alarm working .No .Educated pt (patient) to use call light before getting up and if needs assistance . Review of the care plan dated 5/31/17 revealed it was updated 6/2/17 with the handwritten intervention .educate patient on proper use of call light and to call for assistance w/ (with) mobility and transfers-Ask pt (patient) to demonstrate back correct use of call light and reasons why they should use the call light . This intervention was already in place on the ICP 5/11/17, and the Complete Patient Care Plan 5/31/17. Interview with Physical Therapist #1 on 6/8/17 at 12:15 PM, in the conference room, revealed .Do not have a walking assessment or wheelchair assessment that we complete .that is just something we look at every day when working with a resident . Interview with the Assistant Director of Nursing (ADON) on 6/12/17 at 2:45 PM, in the conference room, revealed .don't recall where I got the information the alarm wasn't sounding .don't remember if investigated . Interview with the RM on 6/12/17 at 3:00 PM, in the conference room, revealed .nurse suggested that as an intervention .was not aware it was something they (therapist) do every day . Continued interview confirmed a walking or wheelchair assessment was not an appropriate intervention. Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, confirmed the resident education to rise slowly when standing and to use the call light before getting up were not appropriate interventions for the resident In summary, Resident #2 experienced 3 falls on 5/19/17, 5/24/17, and 6/2/17. There was no thorough investigation to determine causes of falls with interventions implemented to specifically address those falls. Interventions of educating the resident to use the call light were supposed to have been in place since admission and not a reliable intervention for a resident with impaired cognition. The intervention of walking or wheelchair assessment was a routine assessment performed by therapy. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 discharged from the facility to an ALF on 6/13/17. Medical record review of the Admission Nursing Assessment Report dated 5/23/17 revealed the resident was oriented to self only. Continued review revealed the resident required extensive assist with transfers and 2 person assist. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 17 (severe risk). Medical record review of the ICP dated 5/24/17 revealed .Problem Falls Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad Bed Wheelchair .Scheduled Toileting Program .Assist with mobility between therapy sessions . Medical record review of a facility Post Falls Nursing assessment dated [DATE] at 10:00 AM, revealed PT (patient) was getting up from wheelchair to try to get some deodorant from PT dresser and lost his balance and landed on bottom .Interventions: Medication Review by Pharmacist . Further review revealed the resident did not have any injuries. Medical record review of the Consultant Pharmacist Patient Evaluation dated 5/30/17 revealed the medications were reviewed by the pharmacist with no recommendations for medication changes or adjustments. Interview with the DON on 6/19/17 at 9:00 AM, in the conference room, confirmed no medication changes were made and no additional interventions were implemented to prevent further falls. In summary, Resident #5 fell on [DATE] and the facility's intervention to address the fall and prevent further falls was a pharmacist medication review. The medications were reviewed by the pharmacist with no changes made and there were no other assessments for causes for the fall after it was determined the medications had not contributed to the fall, and no interventions put in place to prevent further falls. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 19 (severe risk). Medical record review of the ICP dated 3/3/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions .WC (wheelchair) seating assessment/WC seat cushion/Adaptive equipment .Activities . Medical record review of the 5 Day MDS dated [DATE] revealed the resident had short-term memory problems and moderately impaired cognition. Continued review revealed the resident required extensive assistance for transfers, dressing, and bathing with 1-2 person assist. Medical record review of the facility Post Falls Nursing assessment dated [DATE] at 7:46 PM revealed .PT (patient) found seated on floor of bathroom in front of toilet. PT pulled emergency cord to alert staff. Could not explain transition to floor. PT had removed non-skid socks and pants . The resident had no injuries. Review of the facility Post Falls Investigation dated 3/9/17 revealed .Someone needs to be with the patient while he is toileting . Medical record review of the Post Falls Nursing assessment dated [DATE] at 3:30 AM, revealed Resident #7 .was found sitting on the floor beside the bed .stated he needed to go to the bathroom .Intervention: Re-educated PT (patient) on the use of the call light and importance of calling for assistance . The resident had no injuries. Review of the facility Post Falls Investigation dated 3/10/17 revealed .Patient needs not to be left unattended while toileting . (Same intervention from fall on 3/9/17.) Medical record review of the ICP revealed a handwritten intervention dated 3/10/17 .reeducated the PT (patient) on proper use of call light and importance of calling for assistance . (Intervention of instruct resident and family to call for assist with mobility/transfers was initiated on 3/3/17). Medical record review of the Post Falls Nursing assessment dated [DATE] at 6:35 AM revealed .CNA responded to alarm sounding and PT (patient) sitting in the floor at bedside .no sitter w(with)/patient this shift . The resident had no injuries. Review of the Post Falls Investigation dated 3/14/17 revealed .requested family stay as much a possible . Medical record review of the Post Falls Nursing assessment dated [DATE] at 4:20 AM revealed .PTS (patient's) daughter was assisting PT to restroom. Daughter stated she stepped out to give her dad privacy. Daughter went back in and found PT on floor. Daughter pulled emergency light in bathroom and staff alerted to room . Review of a Post Falls Investigation dated 3/15/17 revealed .Pt (patient) not to be left alone in bathroom . (Same intervention as 3/9/17 and 3/10/17). Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting .staff makes rounds if observe someone is restless will take them to the bathroom . Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, revealed .we can try to re-educate in hopes that something takes .but not appropriate as an intervention .should have done something else . Continued interview revealed .I think attend while toileting was for a different fall . Further interview confirmed the facility failed to implement an appropriate intervention after the fall on 3/10/17. In summary, Resident #7 had a moderate cognitive impairment and had 4 falls. The ICP intervention to not be left unattended while toileting was an intervention used after 3 of the falls on 3/9/17, 3/10/17, and 3/15/17. The intervention of re-education to use the call light and request assistance was not an appropriate intervention for the fall on 3/10/17 due to the resident's impaired cognition. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 discharged from the facility to ALF on 5/1/17. Medical record review of the Admission Nursing assessment dated [DATE] revealed the resident was alert and oriented with occasional confusion/forgetfulness. Continued review revealed the resident required extensive assist with transfers with 2 person assist. Medical record review of the ICP dated 3/20/17 revealed .Problem: Falls Risk/Potential for injury .Interventions .Fall Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Provide reminders and cues regarding safety as needed .Alarm pressure pad Bed Wheelchair . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 16 (severe risk). Medical record review of a Post Falls Nursing assessment dated [DATE] at 7:00 AM revealed .heard alarm sounding entered room found patient sitting on floor . The resident had no injuries. Review of the Post Falls Investigation dated 3/23/17 revealed the intervention .scheduled toileting . Medical record review of a Post Falls Nursing assessment dated [DATE] at 3:00 AM revealed .observed PT (patient) on floor, supine with legs extended towards the HOB (head of bed) PT states was reaching for the table. Table was observed at the foot of his bed . The resident had no injuries. Review of a Post Falls Investigation dated 3/25/17 revealed Alarm in place and working .Yes .Alarm sounding .No .Scheduled toileting . Medical record review revealed no new interventions were put in place after the

Based on review of facility policy, medical record review, review of the facility incident/accident investigations, and interview, the facility's Quality Assurance Committee failed to ensure timely development of an effective evaluation, implementation, and monitoring system to ensure residents were free from accidents/incidents and were provided adequate supervision to prevent falls for 6 residents (#1, #2, #3, #5, #7, and #9) of 10 residents reviewed. The facility's failure placed Residents #1 and #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility was cited Substandard Quality of Care at F-323 (J). The Administrator, Assistant Administrator, Assistant Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, and the Health Information/Quality Assurance Quality Improvement Coordinator were notified of the Immediate Jeopardy on 6/19/17 at 2:40 PM, in the conference room. The findings included: Resident #1 was admitted to the facility for rehabilitation therapy after a fall with a [MEDICAL CONDITION] requiring surgical repair, with the goal to return home with her husband. The resident was identified as a severe risk for falls upon admission 5/8/17. The facility had care planned safety interventions, including the use of pressure pad alarms to the bed and wheelchair. On 5/20/17 the resident was assisted by the therapist back to her room after therapy. Occupational Therapist (OT) #2 confirmed she was aware the alarm was not functioning, did not know how to fix it, and failed to report it to the nurse. Resident #1 sustained a left wrist fracture and a laceration to her left brow requiring 6 sutures. Interviews confirmed the chair pressure pad alarm was unplugged and did not alarm. The falls investigation and interventions implemented did not address the alarm being disconnected and new interventions of nonskid socks, which the resident was already wearing at the time of the fall, and clear pathways were not based on an investigation of the cause of the fall. Resident #3 was admitted to the facility for rehabilitation therapy with the goal of returning to her previous assisted living setting. The resident was identified as severe risk for falls upon admission to the facility. The resident had a change in antipsychotic medication therapy on 5/22/17. The evening of 5/22/17, the nurse contacted the family and reported the resident had gotten out of bed twice during the shift setting off alarms. The resident was assisted back to bed by the nurse without additional interventions, and left unattended. The resident got up a third time, fell , and sustained a [MEDICAL CONDITION]. The resident was admitted to the hospital, underwent a left hip hemiarthroplasty, returned to the facility on [DATE], and remained in the facility. Resident #2 experienced 3 falls on 5/19/17, 5/24/17, and 6/2/17. There was no thorough investigation to determine causes of falls with interventions implemented to specifically address those falls. Facility documentation after falls indicated implementation of educating the resident to use the call light, which was to have been in place since admission and not a reliable intervention for a resident with impaired cognition. The intervention of walking or wheelchair assessment implemented after one fall was actually a routine assessment performed by therapy. Resident #5 fell on [DATE] and the facility's intervention to address the fall and prevent further falls was a pharmacist medication review. The medications were reviewed by the pharmacist with no changes made and there were no other assessments for causes for the fall after it was determined the medications had not contributed to the fall, and no interventions put in place to prevent further falls. Resident #7 had a moderate cognitive impairment and had 4 falls. The intervention to not be left unattended while toileting was an intervention used after 3 of the falls on 3/9/17, 3/10/17, and 3/15/17. Another intervention of re-education to use the call light and request assistance was not an appropriate intervention for the fall on 3/10/17 due to the resident's impaired cognition. Resident #9 fell on [DATE] with the intervention of scheduled toileting, but the facility did not do scheduled toileting. After a fall on 3/25/17 no new interventions were implemented. After a fall on 4/18/17 the intervention of a fall mat was implemented, however, there was no evidence the fall mat had been placed at the bed side at the time of the fall on 4/24/17. Interview with the Administrator, Director of Nursing, and the Assistant Regional Director of Clinical Services on 6/8/17 at 3:20 PM, in the conference room, revealed .initiated a Quality Improvement Performance Improvement (QAPI) when we recognized we had a pattern .trend with falls . Interview with the facility QAPI Coordinator on 6/19/17 at 9:00 AM, in the conference room, confirmed the QAPI project for falls began on 11/3/16 and the QAPI program was not effective in evaluation, implementation, and monitoring residents with falls. The Immediate Jeopardy was effective 5/20/17 through 6/20/17. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy, was received on 6/20/17. The corrective actions were validated on site through review of documents, observation, and staff interview by the surveyor on 6/20/17. 1. The Administrator, Physician, Director of Nursing, Assistant Director of Nursing, Risk Manager, Maintenance Director, Social Worker, Activities Director, Dietitian, Director of Rehabilitation, and a Certified Nurse Assistant reviewed and updated Resident #3's care plan with the intervention of a concave mattress. Resident #1 had discharged home on[DATE]. 2. Review of a facility document and interview with the DON on 6/20/17 confirmed the DON, ADON, Risk Manager, and Regional Nurses conducted a review of all residents and verified all safety devices were in place and functional as care planned. 3. Reviewed facility in-service records dated 6/19/17 and 6/20/17, and observations and interviews were conducted on 6/20/17 from 4:40 PM to 7:15 PM with 7 RNs, 2 LPNs, 4 CNAs, 2 Therapists, covering both shifts, and the DON, ADON, and the Risk Manager, to validate the nursing and therapy staff had been educated on the use of the alarms. Staff was in-serviced on ensuring interventions were in place, what to do if an alarm is not functioning and staff responsibility to implement additional interventions as needed based on resident needs. Staff received training on procedures for identifying orthostatic [MEDICAL CONDITION] and reporting concerns to the medical staff. Staff was in-serviced on a new electronic tool used to verify alarms and safety equipment are in use and working properly. The electronic tool can be updated 24/7 and is a communication tool between all disciplines. 4. Observations on 6/20/17 beginning at 5:15 PM confirmed the safety measures for 3 additional residents at risk for falls were listed on the Kardex located in the resident's inside door closet and the electronic communication tool was available with safety devices in use and measures had been implemented as assessed and care planned. 5. Review of the facility audit tool, medical record reviews, and observations revealed the facility had implemented evaluation and monitoring of safety interventions/devices, and updated care plans and the electronic communication tool by 6/20/17. Noncompliance continues at a scope and severity D for monitoring of the effectiveness of collective actions to ensure sustained compliance. Refer to F-282 and F-323