Every finding on record at NHC Place at Cool Springs

Based on policy review, [CONDITION(S)]-CoV-2 (COVID-19) testing log, Staff Time and Attendance sheets, and interview, the facility failed to develop and implement a system to track and ensure all staff with medical and religious exemptions for COVID-19 testing were tested twice weekly for the prevention and potential spread of COVID-19 when 3 of 8 staff members (Registered Nurse (RN) #1 and #2, and Nurse Aide (NA) #1) failed to perform COVID-19 testing twice weekly for 3 of 4 weeks (8/15/2022 - 8/21/2022, 8/29/2022 - 9/4/2022, and 9/5/2022 - 9/11/2022) reviewed. This had the potential to effect the residents these employees cared for. The findings include: Review of the facility's policy titled, .Mandatory COVID-19 Vaccine, dated 2/2/2022, revealed .staff who do not receive the COVID-19 vaccination are considered to be at-risk for transmitting COVID-19 to other staff and patients .exemptions .Testing 2x [times]/week prior to shift regardless . Review of the facility's [CONDITION(S)]-CoV-2 Testing Logs and Staff Time and Attendance sheets from 8/15/2022 -9/11/2022 revealed the following employees failed to perform the required twice weekly COVID-19 testing: a. 8/15/2022-8/21/2022 - RN #2 b. 8/29/2022- 9/4/2022 - RN #1 and RN #2 c. 9/5/2022 - 9/11/2022 - RN #1 and NA #1 During an interview on 9/14/2022 at 5:30 PM, the Director of Nursing (DON) was in the room assisting and confirming exempted staff COVID-19 testing, and the DON was asked if she expected her staff to complete the twice weekly testing as required. The DON stated, Yes .

Based on the policy review, medical record review, and interview the facility failed to ensure a current Advance Directive preference was reflected in the Physician's Order for Scope of Treatment (POST) FORM book for 1 of 6 residents (Resident #1) reviewed for Advance Directives. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 was found without a pulse or respirations and staff initiated Cardiopulmonary Resuscitation (CPR) with chest compressions and artificial respirations against the wishes of Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources Administrator were notified of the Immediate Jeopardy on [DATE] at 6:15 PM in the Conference Room. F-678 was cited at a scope and severity of J and is Substandard Quality of Care. A partial extended survey was conducted on [DATE]. The IJ was effective from [DATE] through [DATE]. The IJ was removed on [DATE] when the facility implemented a corrective action plan. Corrective actions were validated by the surveyors on [DATE]-[DATE]. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction. The findings include: Review of the facility policy titled, Code Status/Advance Directives Procedure dated ,[DATE], showed the original, signed POST form was to be placed in a designated book at each nurse's station. The signed paper POST FORM in the Nurse's Station book was to be the only valid form to be used in the event of a patient transfer out of the facility. The policy also showed the Nurses's station book is an extension of the record and is the only place to maintain the current, signed POST FORM. When a resident returns from a hospital stay and there is no change in the patient's code status and/or state specified POST FORM, there is no need for a new POST FORM to be completed. The Nursing staff is to document in the progress notes that the POST FORM was reviewed upon admission/return and no changes were indicated. The Nurse is then to place the signed POST FORM in the nurse's station POST FORM book. A closed medical record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED]. Resident #1 did not wish to be intubated or to have any advanced airway interventions. Review of a progress note dated [DATE] showed the DON made a .call to (Designated Power of Attorney (DPOA)) to review patients resuscitation status. (DPOA) states that it is to remain as previously documented as a DNR . The Point of Care History dated [DATE]-[DATE] showed Resident #1 was independent in eating, required set up help by the staff and had no swallowing problems noted. Review of the 5 day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 was moderately cognitively impaired, was not interviewable, and was independent for eating and drinking. Review of the Care Plan dated [DATE] showed Category: Nutritional Status .Observe for difficulty with chewing/swallowing and consult with SLP (Speech Language Pathologist) as needed . Review of the Occupational Therapist (OT) Therapist Progress and Discharge Summary dated [DATE] showed Resident #1 required set up only assistance prior to following the activity of eating. Review of the progress note dated [DATE] showed Resident #1 was found unresponsive with no pulse or respirations and the facility staff started CPR at 5:42 PM. Resident #1 was transferred to an acute care hospital. The DPOA was notified of the resident's status. There was no current POST FORM signed or completed by the family in the medical record. Review of an Emergency Medical Services (EMS) transport form dated [DATE] documented, .They (facility staff) found him unresponsive and not breathing and they (facility staff) started CPR at 17:45 (5:45 PM) . During an interview conducted on [DATE] at 3:00 PM, the DON confirmed she called the DPOA on [DATE] to discuss Resident #1's resuscitation status and the DPOA confirmed Resident #1's Advance Directive preference should remain a DNR. During an interview conducted on [DATE] at 3:30 PM, the Respiratory Therapist (RT) stated, .he was found unresponsive, had no pulse and was not breathing .when I arrived to the room chest compressions were being performed .I started assisting with ventilations .at that point we did not know resident's code status (the POST FORM was not in the POST FORM book) .EMS arrived, continued CPR, and intubated (placed an advanced airway) the resident . During a telephone interview conducted on [DATE] at 1:15 PM, Licensed Practical Nurse (LPN) #1 stated, .there was not a POST FORM in the (POST FORM) book so we would treat as full code (perform CPR) .we started CPR .that is what we're supposed to do if there is no (POST) FORM in the book, treat like a full code . During an interview conducted on [DATE] at 2:15 PM, the DON confirmed Resident #1 did not have a POST FORM in the POST FORM book at the nurse's station. The DON stated, .it should have been there .I don't know why it didn't get put in the POST FORM book . The DON confirmed Resident #1's wishes were not honored and stated, .his POST FORM was not followed . During an interview conducted on [DATE] at 11:06 AM, LPN #2, who was assigned to Resident #1 on [DATE], stated, .(LPN #1) looked in the (POST FORM) book and there was no POST FORM in the book. Since there was no (POST) FORM in the book we would treat the resident like a Full Code . During an interview conducted on [DATE] at 5:18 PM, the Administrator confirmed Resident #1's POST FORM was not where it should have been in the POST FORM BOOK at the nurse's station on ,[DATE] 2019. The facility's corrective action plan included the following: On [DATE] the facility did the following: A. The DON reviewed Resident #1's chart and concluded that the resident's code status was DNR and the POST FORM should have been in the POST FORM Book. B. The DON initiated audits on 100% of the in house medical records regarding resuscitation status on [DATE]. This audit revealed 8 residents were without POST FORMS completed with the family, 11 residents were without a POST FORM copy in the POST FORM Book at the nurse's station, 9 residents were without information in both areas of the the electronic medical record system (MATRIX). The information was corrected [DATE]. C. Staff education on the POST FORM process was initiated on [DATE] and reeducation completed on [DATE]. D. Monitors of the POST FORM process was initiated with daily look back on Admissions to ensure the process was followed and reeducation conducted as needed with staff. Monitors continue with daily look back for new admissions. E. Health information staff also follows up with a 72 hour audit of records to include the POST FORM Process. F. An admission nurse was hired ,[DATE] to complete the admission paperwork and perform ongoing audits of admission paperwork related to the POST FORM. The facility's corrective action was validated by the surveyors onsite [DATE]-[DATE]. 1. The facility's POST FORM audits from ,[DATE] through ,[DATE] were reviewed. 2. The facility's Quality Assessment Performance Improvement (QAPI) meeting minutes from ,[DATE] and ,[DATE] were reviewed and the root cause analysis and POST FORM information were discussed in the QAPI meetings. 3. A review of all POST FORM Books at the nurse's stations was conducted to ensure documentation of the POST FORMS. Review of the POS [REDACTED]. Review of physician orders revealed the residents had orders for their CPR status and the EMR had the accurate CPR status for all residents. 4. The facility's electronic medical record for CPR Status accuracy was validated for sampled residents reviewed. 5. The surveyors interviewed staff on all shifts including the Admission Nurse regarding the POST FORM process and the POST Form policy/procedure. All staff were knowledgeable of the process of placing the residents POST forms in the POST FORM BOOK.

Based on medical record review, observation, and interview, the facility failed to notify the physician of a pressure ulcer on admission and failed to notify the physician when a Stage 2 pressure ulcer on the coccyx deteriorated to an unstageable pressure ulcer for 1 of 6 (Resident #138) sampled residents reviewed with pressure ulcers which resulted in actual Harm. The findings include: 1. Medical record review revealed Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Hospital Wound Care note dated 7/9/19 documented, .stage 2 pressure injury to sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) . Review of the Admission Observation performed by Licensed Practical Nurse (LPN) #1 dated 7/11/19 revealed a pressure ulcer on the coccyx (tailbone, a bony structure located at the bottom of the vertebral column) that was described as having zero length and depth. There was no documentation the physician was notified of the pressure ulcer on the coccyx. Review of the Weekly Skin Observations dated 7/17/19, 7/17/19, and 7/31/19 performed by LPN #1 revealed the presence of an open area to the coccyx and a nursing skin treatment/intervention of the application of a dressing (with or without topical medications) . There was no documentation the physician was notified of the open area on the coccyx and no documentation a treatment was ordered by the physician for the open area on the coccyx. Review of a General Order dated 7/18/19 and signed by Licensed Practical Nurse (LPN) #1 documented, .Apply [MEDICATION NAME] protective stick (a fast-drying, non-sticky, alcohol free liquid barrier film) to coccyx area every 3 days .Nursing Order . There was no documentation the physician was notified. Review of the Wound Management Observation History dated 8/1/19 performed by LPN #2 documented, .Length .(centimeters) 4.5 .Width (centimeters) .3 .Tissue Type .Slough (the result of protein, fiber strands,and dead skin cells which can slow wound healing) .Wound edges .Irregular .Skin surrounding wound .[DIAGNOSES REDACTED] (redness) . Review of the General Order dated 8/1/19 and signed by LPN #1 documented, .Clean with NS (Normal Saline). Apply [MEDICATION NAME] (gel indicated for dry to moderately exuding wounds such as partial and full thickness pressure ulcers) to wound bed. Apply No Sting Barrier Spray to periwound (around wound) and cover with protective dressing daily until resolved .Nursing Order . There was no documentation the physician was notified that the pressure ulcer had deteriorated and the nursing order for the treatment was not signed by the physician. Review of the Wound Management Observation History dated 8/8/19 performed by LPN #2 documented, Length .(centimeters) .4.5 .Width .(centimeters) .3.3 .Exudate (drainage) .Moderate .Serous (clear, amber, thin and watery) .Tissue Type .Granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) . There was no documentation the physician was notified of the pressure ulcer or that it had deteriorated. Review of the Wound Management Observation History dated 8/15/19 performed by LPN #2 documented, .Length .(centimeters) .4.9 .Width .(centimeters) .4.8 .Depth .(centimeters) .0.1 .Exudate .Moderate . Serous .Tissue Type .Slough . There was no documentation the physician was notified the pressure ulcer had deteriorated further. Interview with the Director of Nursing (DON) on 8/22/19 at 8:20 AM in the Private Dining Room, the DON was asked if a physician ordered the [MEDICATION NAME] treatment for [REDACTED]. I believe she put it in as a general nursing order. Observations in Resident #138's room on 8/21/19 at 10:40 AM, revealed Resident #138 was positioned on an air mattress (a mattress that reduces pressure on the bony prominences of the body). LPN #1 removed the dressing from the coccyx pressure ulcer. The dressing contained serosangious (blood and serous drainage) drainage. The wound measurements were 5.5 centimeters in length and 5.5 centimeters in width. The wound bed was covered with 40% black eschar (dead tissue that is leathery or thick, black, tan or brown) and 60% slough (dried [MEDICAL CONDITION] fluid that is moist, stringy, yellow, tan, green, or brown). The surrounding tissue was bright red with areas of maceration (skin appears lighter in color and wrinkly). The depth could not be determined due to the slough and eschar in the wound bed. Interview with Licensed Practical Nurse (LPN) #3 on 8/21/19 at 5:51 PM in the Private Dining Room, LPN #3 was asked when he first saw Resident #138's coccyx pressure ulcer. LPN #3 stated, (MONTH) 1 (2019) .it was unstageable (full thickness skin or tissue loss with unknown depth of the wound) due to slough . LPN #3 was asked if the pressure ulcer had improved. The LPN #3 stated, No. I don't see that. LPN #3 was asked if a physician had been notified of the pressure ulcer on the coccyx. The Unit Manager stated, I don't know. LPN #3 was asked if he should have notified the physician. LPN #3 stated, Yes, Ma'am. Interview with the DON on 8/22/19 at 8:05 AM in the Private Dining Room, the DON was asked if a physician was notified about the pressure ulcer on Resident #138's coccyx. The DON stated, I don't see documentation that reflects that . The DON was asked if she notified the physician after she observed the pressure ulcer on 8/21/19. The DON stated, .did not . Telephone interview with Physician #1 (Resident #138's physician) on 8/22/19 at 9:58 AM, Physician #1 was asked if he should have been notified that Resident #138 had a pressure ulcer on the coccyx. Physician #1 stated, I suspect so .you want a full team approach .with a worsening wound the nurse should raise the flag . Telephone interview with the Nurse Practitioner on 8/22/19 at 11:27 AM, the Nurse Practitioner was asked if she had seen Resident #138's pressure ulcer. She stated, I have not . The Nurse Practitioner was asked if she expected staff to notify her if a pressure ulcer had deteriorated. The Nurse Practitioner stated, Yes. The Nurse Practitioner was asked when she was notified about Resident #138's coccyx pressure ulcer. The Nurse Practitioner stated, I can't recall .I didn't know about it being worse . The facility failed to notify the physician of a Stage 2 pressure ulcer on the coccyx which deteriorated to an unstageable pressure ulcer and resulted in Harm to Resident #138.

Based on The National Pressure Ulcer Advisory Panel (NPUAP) Quick Reference Guide, facility policy review, medical record review, observation, and interview, the facility failed to provide the necessary treatment for [REDACTED].#53 and #138) sampled residents reviewed with pressure ulcers. The facility's failure to stage or obtain measurements of the pressure ulcer on admission, failure to notify the physician of the pressure ulcer on admission, and failure to identify the stage of the the pressure ulcer until it became unstageable resulted in actual Harm to Resident #138. The findings include: 1. The NPUAP Prevention and treatment of [REDACTED].Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing .Assess the pressure ulcer initially and re-assess it at least weekly .Document the results of all wound assessments .weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound (area around the wound) condition .wound edges .sinus tracts (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation) undermining (occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) .tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle) .exudate (drainage) .odor .Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Unstageable: Depth unknown, Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed . 2. The facility's Skin Integrity Manual revised 3/1/10 documented, .ASSESSMENT .Risk Factors .Example of these risk factors include but are not limited to .Impaired/decreased mobility and decreased functional ability .Co-morbid conditions .Under nutrition, malnutrition, and hydration deficits .Wound assessment includes type, stage, location, and measurement of site .length, width and depth .Exudate .type, odor, amount, color .Wound bed to include .necrotic tissue, slough .Periwound .wound edge appearance to include description and measurement .Weekly Skin and Wound Assessments . 3. Medical record review revealed Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Hospital Wound Care note dated 7/9/19 documented, .stage 2 pressure injury to sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) . The Hospital Discharge Summary dated 7/11/19 documented, .(Resident #138) has developed a decubitus wound . Review of the Admission Observation report dated 7/11/19 revealed Resident #138 had a pressure ulcer on his coccyx (tailbone, a bony structure located at the bottom of the vertebral column). The Admission observation did not identify the stage of the coccyx pressure ulcer and there was no documentation the physician was notified the resident had a pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 8/21/19 at 5:17 PM, in the Private Dining Room, LPN #1 confirmed that she was the admitting nurse for Resident #138 on 7/11/19. LPN #1 was asked to describe Resident #138's coccyx area when he was admitted to the facility. LPN #1 stated, .It was just reddened .top layer of skin removed, denuded skin (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate, or friction) . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #138 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognition, required extensive assistance for bed mobility, was at risk for developing pressure ulcers/injury, and had a stage 2 pressure ulcer on admission. This was the first entry in the medical record that identified the pressure ulcer on Resident #138's coccyx. The Care Plan revised 8/21/19 documented, .Risk for loss or alteration in skin integrity related to presence of Stage 2 sacrum wound .Approach .air mattress maintained at all times .Administer medications and treatments as ordered .Evaluation Notes: 08/21/2019 .wounds assessed this am (morning) with coccyx noted to have slough to 75% of wound and eschar to 25% of wound .air mattress applied and turnq2 (turn every 2 hours) . There were appropriate nutritional approaches were in place. Review of the Weekly Skin Observations dated 7/17/19, 7/24/19, and 7/31/19 by LPN #1 revealed the presence of a pressure ulcer on the coccyx. The Weekly Skin Observations did not identify the stage or measurements of the pressure ulcer. The General Order dated 7/18/19 documented and signed by LPN #1 documented, .Apply [MEDICATION NAME] protective stick (a fast-drying, non-sticky, alcohol free liquid barrier film) to coccyx area every 3 days .Nursing Order . There was no documentation the physician was notified about the new treatment. The Weekly Skin Observation dated 7/31/19 performed by LPN #1 documented, .redness open area to coccyx . The stage of the pressure ulcer was not identified and there were no measurements. There was no documentation the physician was notified about the change in the pressure ulcer. Review of a Wound Management Observation History performed by LPN #3 dated 8/1/19 revealed Resident #138's pressure ulcer had a length of 4.5 centimeters and a width of 3 centimeters with slough in the wound bed and [DIAGNOSES REDACTED] (redness) around the pressure ulcer. There was no documentation that identified the stage of the pressure ulcer. Observations on 8/19/19 at 4:35 PM, 8/20/19 at 10:19 AM, 1:59 PM, and 4:38 PM, in Resident #138's room, revealed Resident #138 did not have an air mattress on his bed. Interview with the LPN #3 on 8/21/19 at 2:44 PM in the Unit Manager office, LPN #3 was asked when he saw Resident #138's pressure ulcer. LPN #3 stated, This is when they brought me in on it .on 8/1 (8/1/19) was my first assessment and I started measuring it. LPN #3 was asked why the stage of the pressure ulcer was not identified on the assessments. LPN #3 stated, You know what? I don't know why I didn't do that. Interview with the Director of Nursing (DON) on 8/21/19 at 4:34 PM, in the Private Dining Room, the DON was asked if a physician had seen Resident #138's pressure ulcer on the coccyx. The DON stated, I don't know. Interview with the DON on 8/22/19 at 8:05 AM in the Private Dining Room, the DON confirmed the pressure ulcer on the coccyx had not been measured until 8/1/19. The DON confirmed the stage of the pressure ulcer on the coccyx had not been identified on the Wound Management Observations between 8/1/19 and 8/21/19. The DON was asked if the nurses should document and report any changes in a pressure ulcer to the physician. The DON stated, Yes, Ma'am. The DON was asked if a physician was notified about the deteriorating coccyx pressure ulcer. The DON stated, I don't see documentation that reflects that . The DON confirmed she had not seen Resident #138's coccyx wound until 8/21/19. The DON was asked if she had notified the physician after she saw the pressure ulcer on 8/21/19. The DON stated, .did not . The General Order dated 8/1/19 documented and signed by LPN #1 documented, .Clean with NS (Normal Saline). Apply [MEDICATION NAME] (gel indicated for dry to moderately exuding wounds such as partial and full thickness pressure ulcers) to wound bed. Apply No Sting Barrier Spray to periwound and cover with protective dressing daily until resolved .Nursing Order . There was no documentation the physician was notified about the change in the wound or the change in the treatment. Interview with the DON on 8/22/19 at 8:20 AM in the Private Dining Room, the DON was asked if a physician had ordered the [MEDICATION NAME] treatment for [REDACTED]. I believe she put it in as a general nursing order. Review of a Wound Management Observation History dated 8/8/19 by LPN #3 revealed the wound had increased in size to a length of 4.5 centimeters and width of 3.3 centimeters with a moderate amount of drainage. This assessment did not identify the stage of the pressure ulcer on the coccyx. There was no documentation the physician was notified the pressure ulcer had deteriorated. A General Order dated 8/14/19 received by LPN #1 documented, .Clean with NS. Apply Santyl nickel thick to wound bed. Apply No Sting Barrier Spray to periwound and cover with protective dressing daily until resolved . Telephone interview with the Nurse Practitioner on 8/22/19 at 11:27 AM, the Nurse Practitioner confirmed she was notified about the pressure ulcer and gave a telephone order for Santyl treatment (a medication that removes dead tissue) on 8/14/19. The Nurse Practitioner was asked if she had seen Resident #138's pressure ulcer. She stated, I have not. Review of the Wound Management Observation History report dated 8/15/19 performed by LPN #3 revealed the wound had progressed to a length of 4.9 centimeters, a width of 4.8 centimeters and a depth of 0.1 centimeters, with slough in the wound bed. This assessment did not identify the stage of the pressure ulcer to the coccyx. Observation in Resident #138's room on 8/21/19 at 10:40 AM, revealed Resident #138 lying on an air mattress. LPN #1 removed the dressing and it was soaked with serosanguinous (blood and serous drainage) drainage. The wound measurements were 5.5 centimeters in length and 5.5 centimeters in width. The wound bed was covered in 40% black eschar and 60% slough. The surrounding tissue was bright red with areas of maceration (skin breakdown). The depth could not be determined due to the slough and eschar in the wound bed. Interview with Certified Nursing Assistant (CNA) #1 on 8/21/19 at 11:05 AM in Resident #138's room, CNA #1 was asked when Resident #138 was placed on the air mattress. CNA #1 stated, Today. Interview with CNA #1 on 8/21/19 at 5:48 PM, in the Second Floor Nurses' Station office, CNA #1 was asked when she first took care of Resident #138. CNA #1 stated, I had him the 18th (7/18/19). CNA #1 was asked if she remembered what his coccyx looked like. CNA #1 stated, It was pretty bad. There was a black spot on it. It was above or on his coccyx, the same place it was now. He came here with it. CNA #1 was asked to describe it. She stated, A little smaller than a tennis ball. CNA #1 was asked what color the wound was. She stated, Black. Interview with Unit Manager #1 on 8/21/19 at 5:51 PM in the Private Dining Room, Unit Manager #1 was asked if the pressure ulcer was improving. Unit Manager #1 stated, No. I don't see that. Telephone interview with Physician #1 on 8/22/19 at 9:58 AM, Physician #1 was asked if he should have been notified about Resident #138's pressure ulcer on the coccyx. Physician #1 stated, I suspect so .you want a full team approach .with a worsening wound the nurse should raise the flag . Interview with the DON on 8/22/19 at 11:45 AM in the Private Dining Room, the DON was asked if LPN #1 or LPN #3 had wound care training. The DON confirmed they had attended wound care inservices in the facility and stated, They are not wound certified. The facility failed to stage and obtain measurements, report to the physician, and treat a pressure ulcer which resulted in actual Harm to Resident #138 when the Stage 2 pressure ulcer on the coccyx deteriorated to an unstageable pressure ulcer. 4. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #53 had a BIMS score of 10, which indicated moderately impaired cognition, and required extensive assistance from staff for bed mobility. The Care Plan dated 8/15/19 documented, .Problem .pressure ulcer .Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue .systematic skin inspection .Keep clean and dry . The Wound Management Observation History dated 8/15/19 performed by by LPN #3 documented, .Pressure Ulcer .Left bottom of foot . This assessment did not include measurements or stage of the pressure ulcer. The physician was not notified about this pressure ulcer until 8/16/19. The physician's orders [REDACTED].clean bottom of left foot with ns (normal saline), pat dry, apply calcium alginate (a highly absorbent, biodegradable alginate dressing derived from seaweed) .cover with 4x4 (a gauze dressing) and wrap with kerlix (sterile and non-sterile gauze rolls used for both primary and secondary dressings), change every three days . Review of the (MONTH) 2019 Treatment Administration Records (TARS) revealed there was no documentation the treatments were administered since ordered on [DATE]. A physician's orders [REDACTED].apply [MEDICATION NAME] wand every three days until healed . Observations in Resident #53's room on 8/21/19 at 8:15 AM, revealed Resident #53 had a clear [MEDICATION NAME] dressing that was dry and intact with a healing stage 2 pressure ulcer on the ball of the left foot. Interview with Registered Nurse (RN) #2 on 8/20/19 at 5:06 PM, in the Second Floor Nurses' Station office, RN #2 was asked what Resident #53's pressure ulcer on the ball of his left foot looked like when she first found it. RN #2 stated, It was a fluid filled pressure ulcer. Interview with the DON on 8/21/19 at 9:23 AM in the Private Dining Room, the DON was asked if treatments were ordered when the wound was identified on the bottom of the left foot on 8/15/19. The DON stated, No, Ma'am. It was on the 16th. The DON confirmed there was no documentation the treatments were administered as ordered.

Based on facility policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a blackish substance in 1 of 1 ice maker, 5 (Dietary Aide #1, Dietary Aide #2, Outside Vendor #1, Outside Vendor #2, Cook #1)facility staff and outside vendors in the kitchen without hair and beard restraints, and 1 of 24 (Certified Nursing Assistant (CNA) #1) staff members placed a meal tray from a resident's room back on the meal cart with clean trays. The facility's failure had the potential to affect 126 of the 127 residents residents receiving a meal tray from the kitchen. The findings include: 1. The facility's Food Service Establishment policy revised (MONTH) (YEAR) documented, .food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn effectively, keep their hair from contacting exposed food .clean equipment, utensils, and linens . Observations in the kitchen on 8/19/19 at 10:40 AM and 8/20/19 at 7:50 AM, revealed a blackish film on the inside walls of the ice machine. Observations in the kitchen on 8/19/19 at 10:45 AM and 8/21/19 at 10:55 AM, revealed Dietary Aide #2 in the kitchen without a hair restraint. Observations in the kitchen on 8/19/19 at 10:47 AM, revealed Outside Vendor #1 walked through the kitchen with a cart of bread without a hair or beard restraint. Observations in the kitchen on 8/19/19 at 10:58 AM and 8/22/19 at 7:40 AM, revealed Dietary Aide #1 was assisting on the front tray line. His mustache was not covered by a hair restraint. Observations in the kitchen on 8/20/19 at 11:10 AM, revealed Outside Vendor #2 walked through the kitchen without a hair restraint. Observations in the kitchen on 8/20/19 at 11:15 AM, revealed Cook #1 did not have a hair or beard restraint. Interview with the Certified Dietary Manager (CDM) on 8/22/19 at 8:43 AM in the Dining Room, the CDM was asked if it was appropriate to have a slimy film in the ice maker. The CDM stated, No ma'am. The CDM was asked if the dietary staff or delivery personnel should wear a hair and beard restraint when in the kitchen. The CDM confirmed the staff and outside vendors should have been wearing hair restraints and stated, .it's frustrating . 2. The facility's SAFETY & SANITATION BEST PRACTICE GUIDELINES policy with a revised date of 11/2017 documented, .To prevent cross-contamination, in-room trays and soiled dishes should not be placed on carts with clean food and trays that have not been served . Observations in the 1100 Hall on 8/19/19 at 11:40 AM revealed CNA #2 carried a meal tray into a resident's room, placed it on the over bed table, and walked out of the room to the meal cart in the hall. The resident was not on the room. At 11:42 AM, CNA #2 went back into the resident's room, picked up the meal tray, carried the meal tray to the meal cart, and placed the dirty tray into the meal cart with 5 clean meal trays. Interview with the Director of Nursing (DON) on 8/22/19 at 8:32 AM in the Private Dining Room, the DON was asked if a meal tray that had been left in a resident room should be placed inside the cart with clean trays. The DON stated, No Ma'am, it is mixing clean and dirty.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide mouth and nail care for 1 of 1 (Resident #29) sampled residents reviewed for ADL care. The findings include: The facility's NURSING POLICIES revised 2/2019 documented, .In the event that an individual patient is unable to participate in his or her own care, center care partners will assure that the patient's hygiene and comfort needs are met . Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitively intact and Resident #29 required extensive assistance of staff for his personal hygiene. Resident #29's Care Plan dated 6/10/19 documented, .Problem .ADL's (activities of daily living), limited ability to perform self care related to: [DIAGNOSES REDACTED].Approach .Assist with all ADL's as needed .Problem .Diabetes .Approach .Foot and nail care . Observations in Resident #29's room on 8/19/19 at 4:37 PM, 8/20/19 at 10:26 AM and 4:42 PM, revealed Resident #29 had cracked lips and his left hand had long fingernails with a thick brown substance under the nails. Observations in Resident #29's room on 8/21/19 at 8:11 AM, revealed Resident #29 had long fingernails with a brown substance under all the nails. Resident #29 was feeding himself with his hands. Resident #29's lips were cracked. Interview with Licensed Practical Nurse (LPN) #1 on 8/21/19 at 3:15 PM in Resident #29's room, LPN #1 was asked to describe the nails on Resident #29's left hand. LPN #1 stated, They need cutting and they need to be cleaned. LPN #1 was asked if Resident #29 should have long nails with a brown substance under the nails. LPN #1 stated, No, it is not acceptable. LPN #1 opened Resident #29's hand to reveal the thumb, index, and middle fingernails were long, thick, and yellow. Interview with Registered Nurse (RN) #1 on 8/21/19 at 4:44 PM at the Continuing Care Nurses' Station, RN #1 was asked who should ensure the residents receive oral care. RN #1 stated, That's not something I do. RN #1 was asked if there were supplies available to moisturize the resident's lips. RN #1 stated, We don't have that available here . Interview with the Director of Nursing (DON) on 8/22/19 at 9:24 AM in the Private Dining Room, the DON was asked if it was appropriate for residents to have long nails with a thick brown substance underneath them. The DON stated, No. The DON confirmed that mouth care should be provided for residents that are unable to perform mouth care for themselves and that there were mouth care supplies available.

Based on facility policy review, medical record review, observation, and interview, the facility failed to monitor for side effects and behaviors and failed to document an appropriate [DIAGNOSES REDACTED].#58) sampled residents reviewed for unnecessary medications. The findings include: The facility's D[NAME]UMENTATION AND COMMUNICATION OF CONSULTANT PHARMACIST RECOMMENDATIONS policy dated 6/2016 documented, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within a reasonable time frame or within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#58 was receiving quetiapine (an antipsychotic medication) 400 milligrams (mg) daily at 8:00 AM with a start date of 7/2/19, quetiapine 400 mg daily at 6:00 PM with a start date of 6/19/19 for a [DIAGNOSES REDACTED]. The [MEDICATION NAME] dosage was changed on 8/15/19 to 0.5 mg daily at bedtime. Review of the Medication Administration Record (MAR) for June, July, and (MONTH) 2019 revealed Resident #58 received quetiapine and [MEDICATION NAME]. There was no documentation of monitoring for side effects or behaviors. The Consultant Pharmacist's Medication Regimen Review dated 6/24/19 documented, .This resident is receiving the antipsychotic agent [MEDICATION NAME] (quetiapine), but lacks an allowable [DIAGNOSES REDACTED].Please provide [DIAGNOSES REDACTED]. The Consultant Pharmacist's Medication Regimen Review dated 7/17/19 documented, .2nd Request .Patient has order for [MEDICATION NAME] .Please add anxiolytic side effect monitoring, antipsychotic side effect monitoring, and psychoactive behavior monitoring .2nd Request .Order for quetiapine has a [DIAGNOSES REDACTED]. This is not an appropriate [DIAGNOSES REDACTED]. order . Observations in Resident #58's room on 8/20/19 at 4:39 PM and on 8/21/19 at 8:17 AM, revealed no verbal response could be elicited from Resident #58. Interview with Unit Manager #2 on 8/21/19 at 3:25 PM in the Unit Manager's office, the Unit Manager #2 was asked if the side effects and behavior monitoring should be documented on the MAR. Unit Manager #2 stated, Yes .I'm not seeing them (side effects and behavior monitoring) on the MAR. Unit Manager #2 was asked if there was an appropriate [DIAGNOSES REDACTED]. Unit Manager #2 confirmed she did not see an appropriate diagnosis.

Based on policy review, observation, and interview the facility failed to ensure the facility was free from accident hazards as evidenced by sharps and aerosol cans in 2 of 116 (room [ROOM NUMBER] and 2303) resident rooms. The findings include: Review of the admission packet form FOR YOUR GUIDANCE revealed .Items that the patient cannot keep in their room .Air fresheners .Any item in aerosol cans .Sharp items such as .scissors . Observations in room [ROOM NUMBER] on 10/15/18 at 11:26 AM and 5:06 PM revealed a pair of scissors on the window sill. Observation in room [ROOM NUMBER] on 10/15/18 at 12:14 PM revealed a screw driver and screws on top of a cart. Observation in room [ROOM NUMBER] on 10/17/18 at 6:00 PM revealed a pair of scissors, 1 bottle aerosol air freshener, and screws on a cart. Interview with the Director of Nursing (DON) on 10/17/18 at 6:25 PM in the DON office, the DON was asked if it was acceptable for aerosol air freshener to be stored in a resident's room. The DON stated, No. The DON confirmed sharps should not be stored in a resident's room.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely as evidenced by unattended medications in 3 of 116 (room [ROOM NUMBER], 1406, and 2303) resident rooms. The findings include: Review of the admission packet form FOR YOUR GUIDANCE revealed, .Items that the patient cannot keep in their room .Any medication items .Over the counter medication .Prescription medications . Observations in room [ROOM NUMBER] on 10/15/18 at 11:26 AM and 5:06 PM revealed 4 syringes of [MEDICATION NAME] (a blood thinner) on the bedside table and 1 bottle of Alcon [MEDICATION NAME] liquid tear eye drops on the over bed table. Observation in room [ROOM NUMBER] on 10/15/18 at 3:40 PM revealed a bottle of Blue Emu (a pain relief cream) and 2 bottles of Peroxyl mouthwash (a medicated mouthwash) on the over bed table. Observation in room [ROOM NUMBER] on 10/15/18 at 11:33 AM revealed 1 bottle of Artic Blast (a pain relieving topical medication) and 1 container of Real Time XX (a pain relief cream) on the window sill. Observation in room [ROOM NUMBER] on 10/15/18 at 5:06 PM revealed a container of [MEDICATION NAME] Plus (a wound cleanser) on the bed side table. Interview with the Director of Nursing (DON) on 10/17/18 at 6:25 PM in the DON office, the DON was asked if Blue Emu cream, [MEDICATION NAME], Alcon [MEDICATION NAME] liquid tear eye drops, and [MEDICATION NAME] Plus should be stored in the resident's room or at the resident's bedside. The DON stated, No. The DON confirmed Artic Blast and Real Time XX should not be stored in the resident's room.

Based on medical record review, observation and interview the facility failed to maintain communication with the [MEDICAL TREATMENT] clinic before and after [MEDICAL TREATMENT] for 1 of 1 (Resident #390) residents reviewed receiving [MEDICAL TREATMENT] care. The findings included: Medical record reveiw revealed Resident #390 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [MEDICAL TREATMENT] Binder revealed no documentation from the [MEDICAL TREATMENT] clinic for Resident #390. Interview with the Director of Nursing (DON) on 11/1/17 at 5:31 PM, in the conference room, the DON was asked if there was any written communication by the nurses to or from the [MEDICAL TREATMENT] clinic. The DON stated, No ma'am.

Based on policy review, medical record review, observation and interview, the facility failed to follow the policy for 1 of 4 (Resident #438) sampled residents reviewed for accidents and the facility failed to ensure the environment was free from accident hazards of unsecured chemicals on 2 of 14 halls (2400 hall and 2200 hall) and in 3 of 116 (Room #2306, 2303, and 2404)) resident rooms. The findings included: 1. The facility's Fall Prevention Program policy documented, PURPOSE: To reduce patient's risk of falling by improving four categories: environmental, transfer, and mobility, equipment, and medications . PR(NAME)EDURE: 1. Complete High Risk Patient Assessment Form a. Upon Admission b. Upon initial fall . Medical record review revealed Resident #438 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The High-Risk Patient Selection form dated 10/6/17 documented, Section 1, Complete Section 1 on admission within 24 hours and with each clinical assessment. Complete Section 2 following an initial fall . The Post Falls Nursing Assessment form dated 10/12/17 revealed Resident #438 fell with no injury. This was Resident #438's first fall since admission. Section 2 of the High-Risk Patient Selection form was not completed after the initial fall. Interview with Assistant Director of Nursing (ADON) #1 on 11/1/17 at 8:50 AM, in the Entrance Lobby, ADON #1 confirmed Section 2 of the High-Risk Patient Selection form was not completed after the initial fall. 2. The facility's .Storage of Hazardous Chemicals policy documented, .Hazardous chemicals are to be stored out of the reach of patients . Observations on the 2400 hall on 10/30/17 at 10:42 AM, 12:20 PM, and 3:16 PM, revealed a canister of bleach wipes sitting on the linen cart beside room #2404. Observations on the 2200 hall on 10/30/17 at 10:46 AM, 12:27 PM, and 3:18 PM , revealed a canister of bleach wipes sitting on an isolation cart next to Room #2203. Interview with the Director of Nursing (DON) on 10/31/17 at 4:56 PM, on the 2400 hall, the DON was asked would you expect bleach wipes to be stored on carts in the hallways. The DON stated, No. Observations in Room #2306 on 10/30/17 at 3:32 PM, 10/31/17 at 7:49 AM, 10:36 AM and 4:49 PM, revealed an aerosol can of disinfectant spray sitting in the windowsill. Interview with the DON on 10/31/17 at 4:50 PM, in Room #2306, the DON confirmed the aerosol can of disinfectant spray was sitting in the windowsill. The DON was asked if it was acceptable for an aerosol can of disinfectant spray to be stored in the resident's room. The DON stated, No. Observations in Room #2303 on 10/31/17 at 7:33 AM, 10:30 AM, 3:13 PM, and 4:45 PM, revealed an aerosol can of air freshener and a spray can of odor eliminator sitting on the bedside table. Interview with the DON on 10/31/17 at 4:46 PM, in Room #2303, the DON confirmed the aerosol can of air freshener and a spray can of odor eliminator was sitting on the bedside table. The DON was asked if the can of air freshener and odor eliminator should be stored in the resident's room. The DON stated, No. Observations in Room #2404 on 10/31/17 at 8:13 AM, 11:18 AM, and 4:52 PM, revealed 1 container of nail polish remover sitting in a wash basin on the chair. Interview with the DON on 10/31/17 at 4:53 PM, in Room #2404, the DON confirmed the nail polish remover was stored in the wash basin in the chair in the resident's room. The DON was asked if it was acceptable for nail polish remover to be stored in the resident's room. The DON stated,No.

Based on policy review, observation, and interview the facility failed to ensure medications were properly secured in 4 of 116 (room [ROOM NUMBER], 2404, 2306 and 2303) resident rooms. The findings included: 1. Review of the facility's MEDICATION STORAGE IN THE CENTER policy documented, .Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications . 2. Observations in room [ROOM NUMBER] on 10/30/17 at 11:27 AM, and 10/31/17 at 5:05 PM, revealed a bottle of Opcon A allergy relief eye drops in the resident's room Interview with the Director of Nursing (DON) on 10/31/17 at 5:06 PM, in room [ROOM NUMBER], the DON confirmed the eye drops were in the room and removed them from the room. The DON was asked if it was acceptable to store eye drops at the bedside. The DON stated, No. 3. Observations in room [ROOM NUMBER] on 10/30/17 at 3:16 PM and on 10/31/17 at 4:53 PM, revealed a tube of Aloe Vera protective skin barrier sitting on the over bed table. Interview with the DON on 10/31/17 at 4:53 PM, in room [ROOM NUMBER],the DON confirmed the tube of Aloe Vera protective skin barrier in the resident's room. The DON was asked if it was acceptable for protective skin barrier to be stored in the resident's room. The DON stated,No. 4. Observations in room [ROOM NUMBER] on 10/30/17 at 3:32 PM, 10/31/17 at 7:49 AM, 10:36 AM and 4:49 PM, revealed a container of Tums (antacid tablets) sitting on the windowsill. Interview with the DON on 10/31/17 at 4:50 PM, in room [ROOM NUMBER], the DON confirmed the container of TUMS was sitting in the windowsill. 5. Observations in room [ROOM NUMBER] on 10/31/17 at 10:30 AM, 3:13 PM and 4:45 PM, revealed a tube of Renegade wound gel sitting on the bedside table, Interview with the DON on 10/31/17 at 4:46 PM, in room [ROOM NUMBER], the DON confirmed the tube of Renegade wound gel was sitting on the bedside table. The DON was asked if the tube of wound gel should be should be stored in the resident's room. The DON stated, No. 6. Observations in room [ROOM NUMBER] on 10/31/17 at 3:13 PM and 4:45 PM revealed a tube of Butt Paste sitting on the bedside table. Interview with the DON on 10/31/17 at 4:46 PM, in Room # 2303, the DON confirmed the tube of Butt Paste was sitting on the bedside table. The DON was asked if the tube of Butt Paste should be should be stored in the resident's room. The DON stated, No.

Based on policy review, medical record review, observation and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained by failing to ensure isolation signage on the doors of 1 of 2 (Resident #443) sampled residents reviewed in isolation and the facility failed to ensure residents were given the correct water pitcher for 2 of 40 (Residents #236 and 190) residents in the stage 1 review. The findings included: 1. Medical record review revealed Resident #443 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].CONTACT PRECAUTIONS .FOR C (Clostridium) DIFF (Difficile) . Observations on the 2200 hall on 10/30/17 at 10:39 AM, 12:37 PM, 3:18 PM, and 5:10 PM and on 10/31/17 at 8:07 AM and 10:39 AM revealed an isolation cart outside the door of Resident #443's room without isolation signage on the door. Interview with Assistant Director of Nursing (ADON) #1 on 11/01/17 at 4:20 PM, in the ADON office, ADON #1 was asked if a resident is in isolation would you expect a sign be on the resident's door related to isolation precautions. ADON #1 stated, Yes, to alert visitors . 2. The facility's .INFECTION CONTROL MANUAL .NURSING . policy documented, .supplies are assembled for each individual patient and are not transported from one room to another or from bed to bed .Patients are provided individualized care items according to their needs .Each patient has an individual covered water pitcher and a tumbler kept on the bedside cabinet . Medical record review revealed Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #236 and #190's room on 10/31/17 at 9:52 AM, revealed Resident #190's water pitcher with straw, labeled with her name, was on Resident #236's overbed table. Resident #236's water pitcher with straw, labeled with her name, was on Resident #190's overbed table. Both water pitchers were labeled with the resident's name but were placed on opposite roommate's table. While the surveyor was in the room, Certified Nursing Assistant (CNA) #1 came out of the restroom with Resident #190 and moved the overbed table next to Resident #190 and said .Let me move your water over so you can reach it . while moving the overbed table with the roommate's water pitcher on it, into her reach. Interview with Registered Nurse (RN) #1 in the doorway of Residents #236 and 190's room on 10/31/17 at 10:01 AM, RN #1 was asked if she could tell me if anything was wrong with Resident #236's water pitcher. RN #1 went to the overbed table and stated, She has her roommate's. I'm horrified, right now . Interview with the Director of Nursing (DON) on 11/1/17 at 2:44 PM, in the conference room, the DON was asked if it was acceptable for the water pitchers to be switched on the overbed tables in a semi-private room. The DON stated, .No, I would not want that to happen.

Based on facility policy review, medical record review and interview, the facility failed to prevent verbal abuse of one resident (#1) of 3 residents reviewed for abuse. The findings included: Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 11/28/16, revealed .Abuse, Neglect, Misappropriation of Patient Property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property, or exploitation must report the event immediately .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of property did or did not occur .The Administrator or Director of Nursing will determine the direction of the investigating once notified of the alleged incident . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed CNA #1 was overheard on 3/22/17 telling the resident she was dirty, stunk, and needed a bath. Continued review revealed CNA #3 reported to the facility Team Coordinator that CNAs were verbally and physically inappropriate during early morning resident care. Further review revealed CNA #1 was suspended during the investigation and CNA #2 was inserviced on the types of abuse and what to do if abuse was suspected. Review of a report by Resident #1 given to Social Services revealed CNA #1 told her You stink, and are dirty and need a bath. Continued review revealed CNA #1 also hit her on the back of the head with her hand and stated since the resident had dirtied her Depend (disposable undergarment) she could throw it away. Review of a written statement from the nurse on duty on 3/22/17 revealed he entered the room of Resident #1 to give her morning medications. Continued review revealed the resident said she had something to tell him and had a frightened look on her face. She stated the two CNAs were very disrespectful and truly rude to her. Review of a written statement from the Social Worker on 3/22/17 revealed she spoke with Resident #1 who stated at 6:00 AM the 2 techs, CNA #1 and CNA #2, were helping her in the bathroom. She sat on the commode when they told her she stunk. She replied No ma'am, I don't stink. Continued review revealed CNA #1 hit the resident on the back of the head with her hand and stated, You dirtied your Depend so you can be the one to throw it away. Further review revealed the CNAs made her pick up her Depend from the floor multiple times because she missed the garbage can several times. Review of a written statement by the ADON on 3/22/17 revealed Resident #1 reported CNA #1 said comments which were hurtful to her and hit her on the back of the head. CNA #1 said she was dirty, stunk, and popped her on the right side of the back of the head. Continued review revealed the ADON assessed the resident and found no obvious injury. Neurological checks were within normal limits. Review of a written statement by CNA #2 on 3/22/17 revealed she told CNA #1 to sit Resident #1 on the toilet and turn on the shower. CNA #2 was making the bed but could hear CNA #1 and Resident #1 getting into it. Continued review revealed Resident #1 kept saying CNA #3 gave me a bath last night. I am not dirty CNA #1 said Your Depend is dirty. You stink. This is a new day. You need a shower. Interview with the Administrator and Director of Nursing on 4/5/17 at 1:30 PM in the conference room confirmed the incident of verbal abuse by CNA #1 and the termination of CNA #1.

Based on medical record review and interview, the facility failed to revise the care plan to reflect the resident's current status for self-administration of medication for 2 of 13 (Residents #190 and #464) sampled residents of the 32 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with readmission date of [DATE] with [DIAGNOSES REDACTED]. Interview with the Regional Case Mix Nurse, Registered Nurse (RN) #4 on 8/9/16 at 3:15 PM in the Director of Nursing's office, RN #4 was asked if residents self-administration of medications should be reflected in the comprehensive care plan. RN #4 stated, Yes. RN #4 was asked if Resident #190's comprehensive care plan reflected self-administration of medications. RN #4 stated, I don't see it The comprehensive care plan for Resident #190 did not reflect self-administration of medications. 2. Medical record review for Resident #464 revealed the resident was admitted to the facility 8/5/16 with [DIAGNOSES REDACTED]. Resident #464's INTERIM PLAN OF CARE dated 8/7/16 did not address respiratory care or self-administration of medication. Interview with RRT #2 in the conference room on 8/9/16 at 4:50 PM in the conference room, RRT #2 verified Resident #464's care plan did not address self-administration of medication.

Based on policy review, medical record review, observation and interview, the facility failed to ensure 3 of 13 (Residents #69, #190 and #464) residents observed were not assessed by an interdisciplinary team (IDT) to self administer medications. The findings included: 1. The facility's MEDICATION ADMINISTRATION Guidelines for Self Administration and Securing Medications policy documented, PURPOSE: As part of their overall evaluation, we will assess each patient's mental and physical abilities, to determine whether a patient is capable of self-administering medications . 2. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #69's room on 8/8/16 at 8:52 AM, revealed Resident #69 was lying on his back in bed with a nebulizer mask over his face and visible mist diffusing from the mask. The nebulizer was powered on and functioning and there was no staff member in the resident's room. Interview with Registered Respiratory Therapist (RRT) #1 on 8/9/16 at 10:40 AM, at the 2nd floor nurses station, RRT #1 was asked if Resident #69 self-administered his nebulizer treatments. RRT #1 stated, Yes. RRT #1 was asked how staff determined residents could safely self-administer their nebulizer treatments. RRT #1 stated, We basically have them do it on their own, in front of respiratory therapy . 3. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #190's room on 8/7/16 at 5:00 PM and 8/8/16 at 10:10 AM, revealed a nebulizer mask on Resident #190's face with a visible mist diffusing from the mask. The nebulizer was powered on and functioning and no staff member was in the resident's room. Interview with Registered Nurse (RN) #1 on 8/8/16 at 5:21 PM, at the 2nd floor nurses station, RN #1 was asked if Resident #190 self-administered his nebulizer treatments. RN #1 stated, Yes . 4. Medical record review for Resident #464 revealed the resident was admitted to the facility 8/5/16 with [DIAGNOSES REDACTED]. Medical record review revealed a Respiratory Therapy Evaluation dated 8/8/16 documented, .Pt (patient) takes [MEDICATION NAME] and [MEDICATION NAME] inhalers at home and was educated and demonstrates good technique and can take on own Observations in Resident #464's room [ROOM NUMBER]/9/16 at 9:29 AM, revealed RN #2 prepared the resident's nebulizer with a unit dose vial containing 3 milliliter of [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]), turned on the nebulizer, handed the mask to Resident #464, and asked the resident if she was ready for her breathing treatment. Interview with RN #2 at the medication cart beside the doorway to Resident #464's room on 8/9/16 at 9:35 AM, RN #2 stated to the surveyor Resident #464 had been assessed (by RRT) for self-administration of her nebulizer and had a physician's orders [REDACTED]. 5. Interview with RRT #2 on 8/9/16 at 4:50 PM, in the conference room, RRT #2 was asked if residents were allowed to self-administer their nebulizer treatments. RRT #2 stated, .The nurse puts the medicine in the cup, puts the mask on their face and leaves the room and comes back in 15 minutes and takes it off .I'm not gonna lie, there's nobody in the room with them . Interview with Director of Nursing (DON) on 8/9/16 at 5:39 PM in the conference room, DON stated there is no documentation of an IDT assessment for self-administration of medication. There was no interdisciplinary team self-administration of medication assessment performed.

Based on facility policy, record review, observation and interview, the facility failed to ensure urinary catheters were maintained in a manner to prevent the potential spread of infection when the Foley catheter was observed touching the floor for 1 of 1 (Residents #214) sampled residents of the 10 residents with urinary catheters. The findings included: 1. The facility's CATHETER DRAINAGE SYSTEM, CLOSED policy documented, .IMPORTANT .Never allow drainage bag to touch floor . 2. Medical record review revealed Resident #214 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 7/26/16 documented, .PROBLEM .Bladder Functioning .APPROACHES .Leg band for positioning of catheter tubing . Observations in the dining room on 8/7/16 at 11:48 AM, revealed Resident #214 sitting in a wheelchair with his catheter bag not covered by the dignity bag when sitting in the dining room while other residents were present. Observations in the Activity Room on 8/7/16 at 12:08 PM, revealed Resident #214 sitting in a wheelchair with his catheter bag not covered with a dignity bag and the foley tubing lying on the floor while other residents were present. Observations in Resident #214's room on 8/8/16 at 4:19 PM, revealed Resident #214 lying in bed with eyes closed with his catheter bag in a dignity bag touching the floor. Interview with Registered Nurse (RN) #3 on 8/8/16 at 4:22 PM, in Resident #214's room, RN #3 was shown Resident #214's catheter bag that was in the dignity bag and was asked if it was appropriate for a dignity bag to be touching the floor. RN #3 stated, .no . Interview with the Director of Nursing (DON) on 8/8/16 at 4:51 PM, in the Conference Room, the DON was asked if a resident had a catheter if it was appropriate for it to be kept in a dignity bag. The DON stated, Yes Ma'am. The DON was asked if it was appropriate for the catheter tubing or the dignity bag to be lying on the floor. The DON stated, No, Ma'am.

Based on review of an investigation report, review of incident reports, record review, review of a family meeting, review of recipes, observation, interview, review of activity logs and policy review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure was evidenced by the following deficient practices found during the recertification survey as documented in the below findings. The facility transferred a resident residing in the facility, who exhibited inappropriate sexual behaviors (comments and gestures), to the courtyard Unit (a secured memory unit that housed 26 vulnerable residents). This transfer created the potential for the 26 residents residing in that secured unit to be at risk for harm from abuse of a sexually inappropriate nature, which resulted in Immediate Jeopardy (IJ), a situation in which the facility's non-compliance has caused or is likely to cause, serious harm, injury, impairment or death to a resident. The Administrator was informed of the IJ on 8/12/15 at 2:47 PM. The facility submitted an acceptable allegation of compliance (AOC) which included resident behavior assessments, revisions to behavior care plans, interventions related to behaviors, staff in-services on abuse/neglect and quality assurance tracking/trending of resident behaviors as related to abuse/neglect. The validation of the AOC abated the IJ on 8/14/15 at 6:05 PM. Non complaince for F490 continues at an E level. The facility is required to submit a Plan of Correction. The findings included: 1. The facility failed to assess and implement appropriate interventions and services to protect the 26 cognitively impaired vulnerable residents residing in the courtyard (secured memory unit) from potential abuse/neglect situations involving inappropriate sexual behaviors when on repeated occasions 1 of 1 (Resident #548) sampled resident demonstrated inappropriate sexual comments and actions directed at staff and residents. The facility submitted an acceptable allegation of compliance (AOC) which included resident behavior assessments, revisions to behavior care plans, interventions related to behaviors, staff in-services on abuse/neglect and quality assurance tracking/trending of resident behaviors as related to abuse/neglect. The team upon receipt of the facility Abatement Plan did confirm the AOC on 8/14/15. The team reviewed the Abuse training slides and staff attendance sheets provided by the facility and conducted staff interviews on all shifts to include nurses and housekeeping, laundry and administrative staff to ensure all staff had an adequate understanding of the education on Abuse provided by the facility. The survey team reviewed sampled residents for any further concerns related to potential Abuse. The team reviewed the care plans for all residents in the census who were identified as having behaviors to ensure appropriate interventions were initiated and utilized to address those specific behaviors. Behavior monitoring sheets were reviewed to ensure targeted behaviors for residents were being monitored by staff. Administrative staff were interviewed to ensure an adequate understanding of appropriate ongoing monitoring was in place to ensure Facility systems for the identification of abuse and behaviors would be timely in order to implement interventions to protect all residents in the facility. The validation of the AOC abated the IJ on 8/14/15 at 6:05 PM. Refer to F224. 2. The facility failed to investigate injuries of unknown origin for 2 of 22 (Resident #64 and 118) sampled residents. Refer to F225. 3. The facility failed to provide activities that met the physical, mental, and psychosocial needs for 2 of 22 (Residents #27 and 118) sampled residents. Refer to F248. 4. The facility failed to ensure resident care plans were updated based on assessment and identified need for 3 of 22 (Residents #313, #584, and #564) sampled residents. Refer to F279. 5. The facility failed to ensure a resident who exhibited inappropriate sexual behaviors received appropriate treatment and services for the assessed problem for 1 of 1 (Resident #584) who exhibited inappropriate sexual behaviors. Refer to F319. 6. The facility failed to provide a safe environment for 3 of 22 (Residents #313, #564 and #566) sampled residents. Resident #564 and #566 received fractures and/or lacerations. Refer to F323. 7. The facility failed to administer medications appropriately for Resident #39 and #213. One of 4 nurses (Licensed Nurse E) made 3 errors out of 25 opportunities for error, resulting in a medication error rate of 12 percent. Refer to F332. 8. The facility failed to follow the recipes for the preparation of food and failed to follow the serving sizes for the serving of food for one of one meal observed. Sixteen of 153 residents received chopped or pureed diets from the main kitchen. Refer to F363. 9. The facility failed to serve, prepare, and distribute food in a sanitary manner for 2 of 2 days observed. The facility identified a census of 153 residents that received meals from the main kitchen. Refer to F371. 10. The facility failed to ensure 1 of 153 (Resident #577) residents residing in the facility had a working call light. Refer to F463.

Based on review of an investigation report, review of incident reports, record review, review of a family meeting, review of recipes, observation, interview, review of activity logs and policy review, the facility Quality Assurance Committee failed to identify issues with respect to which quality assessment and assurance activities are necessary; and develop and implement appropriate plans of action to correct identified quality deficiencies as evidenced by the following deficient practice found during the recertification survey as documented in the below findings. The facility transferred a resident residing in the facility, who exhibited inappropriate sexual behaviors (comments and gestures), to the courtyard Unit (a secured memory unit that housed 26 vulnerable residents). This transfer created the potential for the 26 residents residing in that secured unit to be at risk for harm from abuse of a sexually inappropriate nature, which resulted in Immediate Jeopardy (IJ), a situation in which the facility's non-compliance has caused or is likely to cause, serious harm, injury, impairment or death to a resident. The Administrator was informed of the IJ on 8/12/15 at 2:47 PM. The facility submitted an acceptable allegation of compliance (AOC) which included resident behavior assessments, revisions to behavior care plans, interventions related to behaviors, staff in-services on abuse/neglect and quality assurance tracking/trending of resident behaviors as related to abuse/neglect. The validation of the AOC abated the IJ on 8/14/15 at 6:05 PM. Non complaince for F520 continues at an E level. The facility is required to submit a Plan of Correction. The findings included: 1. Interview with Administrative Staff V on 8/14/15 at 7:30 PM, Administrative Staff V reported all facility staff are able to identify concerns for the Quality Assurance Committee to review. The Committee used audit tools and prior survey results along with Quality Indicators to identify potential concerns to be brought before the Quality Assurance (QA) Committee. Currently weight loss, [MEDICAL CONDITION] medications, falls, pressure ulcers, infection control and resident satisfaction surveys are discussed during the Meetings. Once an issue was corrected and an action plan was in place, then the QA review was discontinued. The areas of concern identified during the 2015 recertification survey were not identified as problems within the facility by the QA Committee and were not under review. 2. The facility failed to assess and implement appropriate interventions and services to protect the 26 cognitively impaired vulnerable residents residing in the courtyard (secured memory unit) from potential abuse/neglect situations involving inappropriate sexual behaviors when on repeated occasions 1 of 1 (Resident #548) sampled resident demonstrated inappropriate sexual comments and actions directed at staff and residents. The facility submitted an acceptable allegation of compliance (AOC) which included resident behavior assessments, revisions to behavior care plans, interventions related to behaviors, staff in-services on abuse/neglect and quality assurance tracking/trending of resident behaviors as related to abuse/neglect. The team upon receipt of the facility Abatement Plan did confirm the AOC on 8/14/15. The team reviewed the Abuse training slides and staff attendance sheets provided by the facility and conducted staff interviews on all shifts to include nurses and housekeeping, laundry and administrative staff to ensure all staff had an adequate understanding of the education on Abuse provided by the facility. The survey team reviewed sampled residents for any further concerns related to potential Abuse. The team reviewed the care plans for all residents in the census who were identified as having behaviors to ensure appropriate interventions were initiated and utilized to address those specific behaviors. Behavior monitoring sheets were reviewed to ensure targeted behaviors for residents were being monitored by staff. Administrative staff were interviewed to ensure an adequate understanding of appropriate ongoing monitoring was in place to ensure Facility systems for the identification of abuse and behaviors would be timely in order to implement interventions to protect all residents in the facility. The validation of the AOC abated the IJ on 8/14/15 at 6:05 PM. Refer to F224. 3. The facility failed to investigate injuries of unknown origin for 2 of 22 (Resident #64 and 118) sampled residents. Refer to F225. 4. The facility failed to provide activities that met the physical, mental, and psychosocial needs for 2 of 22 (Residents #27 and 118) sampled residents. Refer to F248. 5. The facility failed to ensure resident care plans were updated based on assessment and identified need for 3 of 22 (Residents #313, #584, and #564) sampled residents. Refer to F279. 6. The facility failed to ensure a resident who exhibited inappropriate sexual behaviors received appropriate treatment and services for the assessed problem for 1 of 1 (Resident #584) who exhibited inappropriate sexual behaviors. Refer to F319. 7. The facility failed to provide a safe environment for 3 of 22 (Residents #313, #564 and #566) sampled residents. Resident #564 and #566 received fractures and/or lacerations. Refer to F323. 8. The facility failed to administer medications appropriately for Resident #39 and #213. One of 4 nurses (Licensed Nurse E) made were 3 errors out of 25 opportunities for error, resulting in a medication error rate of 12 percent. Refer to F332. 9. The facility failed to follow the recipes for the preparation of food and failed to follow the serving sizes for the serving of food for one of one meal observed. Sixteen of 153 residents received chopped or pureed diets from the main kitchen. Refer to F363. 10. The facility failed to serve, prepare, and distribute food in a sanitary manner for 2 of 2 days observed. The facility identified a census of 153 residents that received meals from the main kitchen. Refer to F371. 11. The facility failed to ensure 1 of 153 (Resident #577) residents residing in the facility had a working call light. Refer to F463. The facility Quality Assurance Committee failed to develop a systemized approach to identify and address the above deficient practices.

Based on review of an investigation report, record review, review of a family meeting, interview and policy review, the facility failed to assess and implement appropriate interventions and services to protect all cognitively impaired vulnerable residents residing in the courtyard (secured memory unit) from potential abuse / neglect situations involving inappropriate sexual behaviors when on repeated occasions 1 of 1 (Resident #548) sampled resident demonstrated inappropriate sexual comments and actions directed at staff and residents. The facility transferred a resident residing in the facility, who exhibited inappropriate sexual behaviors (comments and gestures), to the courtyard unit (a secured memory unit that housed 26 vulnerable residents). This transfer created the potential for the 26 residents residing in that secured unit to be at risk for harm from abuse of a sexually inappropriate nature. This finding resulted in Immediate Jeopardy (IJ), a situation in which the facility's non-compliance has caused or is likely to cause, serious harm, injury, impairment or death to a resident. The Administrator was informed of the IJ on 8/12/15 at 2:47 PM. This IJ resulted in a Substandard Quality of Care. The extended survey was completed on 8/14/15. The facility submitted an acceptable allegation of compliance (AOC) which included resident behavior assessments, revisions to behavior care plans, interventions related to behaviors, staff in-services on abuse/neglect and quality assurance tracking/trending of resident behaviors as related to abuse/neglect. The validation of the AOC abated the IJ on 8/14/15 at 6:05 PM. Non complaince for F224 continues at an E level. The facility is required to submit a Plan of Correction. The findings included: Resident #584 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the elopement risk assessment completed 2/2/15, indicated Resident #584 was not an elopement risk as indicated by the answer to question fourteen (14) on the assessment: Is the resident an elopement risk? The answer indicated was NO. Review of a staff drawing on 2/12/15 to determine Resident #173's position when found in the central bathroom, showed the resident lying sideways in front of the toilet, her head facing the door. The drawing also showed a pair of eyeglasses on the floor in the corner of the bathroom to the right of the toilet. The glasses were identified to be worn by Resident #584. Review of an investigation report dated 3/18/15, revealed on 2/11/15 at 7 PM, A male resident (#584) was escorted from a central bathroom to his room by a nurse. After the resident was escorted to his room, the nurse went back to the central bath to retrieve the resident's wheelchair that had been left behind. Upon entering the central bath, the nurse discovered a female resident (#173) on the floor of the central bathing area with her depends and pants down to her shins lying in front of the toilet. Resident (#173) was assessed by the nurse and found to have no injuries. The physician, family and local authorities were notified of the occurrence. The investigation report, revealed a series of resident observations, staff interviews and additional record reviews were implemented on 2/12/15, to evaluate Resident #584's behaviors and to determine if a sexually inappropriate incident had occurred in the central bathroom. Review of Resident #584's admission Minimum Data Set (MDS a comprehensive assessment of resident's function capabilities and identification of health problems) dated 2/9/15, revealed Resident #584 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated independent cognitive skills for daily decision making. The resident had unrestricted ability to express ideas and wants along with understanding and interpreting verbal communication. Resident #584 utilized a walker or self-propelled in a wheelchair and was coded to need limited assistance of one (1) staff member as needed to move between locations in his room and adjacent corridors on the same unit. Review of nurses' note revealed the following: a. 2/7/15 at 5 PM - Resident called nurse over to bed and made a comment. You know how I have a brain stimulator? Well, I'm stimulated right now. The nurse then realized the resident was being inappropriate as his penis was showing out of his jeans. The resident was told by the nurse his actions were inappropriate and would not be tolerated at this facility. b. 2/8/15 (no time) - repeatedly made sexual comments toward staff and asked the nurse to sit on his lap so he could scratch her back which was immediately reported to the nurse. The nurse reminded the resident about being inappropriate. Later, the resident told the tech (technician) he wanted to lick her and her friend all over. The resident was again reminded by the nurse about the inappropriate comments. An additional nurses' note dated 2/8/15 (no time) revealed Resident #584 asked the nurse if she wanted to get in the bed with him and exercise. The resident was once again reminded of the inappropriate behavior and instructed to call for help when getting out of or getting back into bed. The resident took apart all alarms in place used to notify staff of his rising. c. 2/9/15 (no time) - indicated the plan for Resident #584 was to move to the memory unit tomorrow (2/10/15). The resident was transferred to the memory unit on 2/10/15, before the psychiatric evaluation had taken place. Review of a family orientation meeting conducted at the facility regarding Resident #584 on 2/9/15 at 10 AM, revealed the family reported past occurrences of the resident displaying some socially/sexually inappropriate behaviors that may carry over to his present environment. During the meeting the social worker obtained consent from the family for the resident to receive psychiatric services. There was also a discussion regarding the resident being transferred to the Courtyard Memory Care Unit. Review of a Social Worker (SW) note dated 2/9/15, (no time) indicated Resident #584 had been acting socially/sexually inappropriate toward staff and current roommate. Nursing reports the resident has been going through his roommate's drawers and opening the privacy curtain with no clothes on. Staff encouraged to continue to provide education and inform social work when resident acts inappropriately. Review of a history and physical note from Consultant Staff U dated 2/12/15, indicated a visit to Resident #173 to review medical issues. This note is in reference to the investigation of a female resident being found lying on the floor in the common bathroom on the evening of 2/11/15. Staff U stated in the note, he/she received a report from the facility the evening of 2/11/15, regarding a female resident (#173) who was found on the floor of the common bathroom, along with a male resident (#584) exiting the bathroom around the same time. The note stated the caller was uncertain whether the female resident (#173) and the male resident (#584) had been in the bathroom at the same time. The caller had also informed Staff U that the female resident (#173) was assessed to have no injuries. The note stated Staff U would be in the facility tomorrow (2/12/15) to examine the female resident (#173). Further review of the note indicated Staff U had examined the female resident the morning of 2/12/15, and found no evidence of trauma. Review of a discharge note dated 2/12/15, indicated Resident #584 was transferred to a Psychiatric Unit that day for evaluation related to inappropriate sexual behavior directed toward facility residents and staff. Resident #584 did not return to the facility. Resident #584 was in the facility nine (9) days. Interview was with administrative staff A and B on 8/12/15 at 10:35 AM, administrative staff A and B were asked why Resident #584 was not sent out for a psychiatric evaluation when he first exhibited sexually inappropriate behaviors on 2/7/15. Also, they were asked why the decision was made to transfer Resident #584 to the Courtyard Memory Unit on 2/11/15. Administrative Staff A stated the resident was transferred to the Courtyard related to his elopement risk. No answer was given regarding why Resident #584 was not sent out for a psychiatric evaluation when the sexually inappropriate sexual behaviors were first reported by nursing on 2/7/15. Interview on 8/12/15 at 10:45 AM, SW X stated Resident #584 only exhibited sexually inappropriate behaviors to staff and indicated a referral for a psychiatric evaluation had been initiated on 2/9/15. Interview was attempted with Resident #173 on 8/12/15 around 11:15 AM, the resident, who was nonverbal and cognitively impaired, was unable to be interviewed regarding the bathroom incident. Review of Resident #173's face sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], revealed Resident #173 had a BIMS score of 99, which indicated unable to be tested . The resident was nonverbal and could not make self understood or understand others. Resident #173 ambulated aimlessly throughout the Courtyard Unit. Interview with Licensed Nursing Staff S on 8/12/15 at 1:15 PM, regarding the bathroom incident, Staff S expressed his/her terror upon finding Resident #173 on the floor in the common bathroom along with providing the following information. Staff S was looking for Resident #584 in order to pass the resident's medications. The resident was finally located in the common bathroom. When Staff S tried to enter the bathroom, the door was locked. Resident #584 finally opened the bathroom door and was sweating profusely. The door was opened only enough for Resident #584 to slip out and close it. The resident grabbed staff S on the right side, pulling the nurse down the hall and would not let go. Staff S was able to get the resident to his room and seated on the bed assisted by another nurse. Staff S realized Resident #584's wheelchair had been left and ran back to the central bathroom to retrieve it (approximately two (2) minutes). When Staff S opened the bathroom door, Resident #173 was lying on the floor in the lithotomy position (lying on back with hips and knees flexed and the thighs apart). Staff S was horrified and immediately assessed the resident for injuries and made the necessary phone calls. Resident #173 was assessed to have no injuries. Interview on 8/12/15 at 1:37 PM, Consultant Staff U stated based on the information obtained by staff during the call, a decision had been made to not subject Resident #173 to the trauma of a trip to the emergency room as there was no physical signs of injury. Review of the facility policy titled Resident Protection and Response for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property revised 5/1/10, defined sexual abuse to include, but not limited to, sexual harassment, sexual coercion, or sexual assault. Any alleged acts of sexual abuse will be investigated and dealt with to ensure resident safety and freedom from the risk of abuse or neglect. The facility submitted an acceptable allegation of compliance (AOC) which included resident behavior assessments, revisions to behavior care plans, interventions related to behaviors, staff in-services on abuse/neglect and quality assurance tracking/trending of resident behaviors as related to abuse/neglect. The team upon receipt of the facility Abatement Plan did confirm the AOC on 8/14/15. The team reviewed the Abuse training slides and staff attendance sheets provided by the facility and conducted staff interviews on all shifts to include nurses and housekeeping, laundry and administrative staff to ensure all staff had an adequate understanding of the education on Abuse provided by the facility. The survey team reviewed sampled residents for any further concerns related to potential Abuse. The team reviewed the care plans for all residents in the census who were identified as having behaviors to ensure appropriate interventions were initiated and utilized to address those specific behaviors. Behavior monitoring sheets were reviewed to ensure targeted behaviors for residents were being monitored by staff. Administrative staff were interviewed to ensure an adequate understanding of appropriate ongoing monitoring was in place to ensure Facility systems for the identification of abuse and behaviors would be timely in order to implement interventions to protect all residents in the facility. The validation of the AOC abated the IJ on 8/14/15 at 6:05 PM.

Based on record review, review of incident reports, review of a investigative report, observation, interviews and policy review, the facility failed to provide a safe environment for 3 of 22 (Residents #564, #566 and #313) sampled residents. Resident #564 sustained a laceration to the forehead and a fractured neck and Resident #566 received a fractured hip and humerus, which resulted in actual harm. The findings included: 1. Resident #564 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The most recent wheelchair assessment dated [DATE] instructed the staff to adjust the footrests for the resident. The 3/31/14 Monthly Nursing Summary Report revealed the resident required a 2 person assist. The resident was very pleasant during the day but tended to sundown in the evenings and will often request to go home repeatedly. At night the resident may become upset and ask for his/her mommy or daddy or to go to his/her house right across the street. The annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems, and displayed no behaviors. The resident required extensive assistance of two people with bed mobility and transfers, required extensive assistance of one person with locomotion on the unit, dressing, eating, toilet use, and personal hygiene, and required total assistance with bathing. The resident was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet, and surface to surface transfers. The activity of walking and turning around did not occur and the resident used a wheelchair. The resident did not have any falls since the previous assessment. The resident received antianxiety and antidepressants 7 of 7 days of the observation period. The resident did not receive physical or occupational therapy services and did not receive restorative services. The Restorative note dated 4/10/14 documented the resident was dependent for mobility and transfers. The Care Area Assessment (CAA) dated 4/22/14 for falls revealed the resident was assisted with activities of daily living to decrease risk of falls. The Care Area Assessment for cognition revealed the resident had a [DIAGNOSES REDACTED]. The care plan with start dates of 4/22/14 listed interventions: fall risk assessment on chart, staff to assist the resident to and from activities as tolerated, keep bed in lowest position, make staff aware of risk for falls, monitor adverse effects of psychotropic medications that affect gait, keep side rails up to increase resident's mobility and independence, transfer the resident with assistance of 2 people, wheelchair assessment, gait belt suggested for transfers for better stability, provide incontinence care after each incontinent episode, ensure access to eyeglasses and encourage him/her to wear, assess for appropriate fit of glasses and scratches or breakage, fall mats at bedside, and direct care staff to stay with the resident while in the bathroom. The care plan lacked interventions for the use of the footrest on the wheelchair. Nurse's note dated 5/25/14 at 1:57 AM, revealed on 5/24/14 at 8:30 PM the resident fell from the wheelchair in the resident's room. The resident had a laceration to the forehead with edema. The resident's blood pressure went from 178/78 to 182/88 and the family wanted the resident transferred to the hospital. When the 911 team transferred the resident from the bed to the stretcher the resident complained of neck pain. Review of the facility's Investigation dated 6/2/14 revealed Administrative Nursing staff B's statement dated 6/2/14 included the resident's child stated the resident had received a fractured bone in his/her neck and was in a neck brace. The signed statement of the direct care staff member revealed, the nurse told this direct care staff member to put the resident to bed. He/she did not want to put the resident to bed just to have to get the resident up again. The direct care staff member put 4 people to bed and was coming back for someone else when the nurse asked this direct care staff again to put the resident to bed. This direct care staff member helped another staff member put a resident to bed. When this direct care staff member was pushing Resident #564 into his/her room and beside the bed the resident put his/her foot down and rolled out of the wheelchair. The resident went down head first. The clinical record and investigation lacked evidence the foot pedals were present on the wheelchair per the wheelchair assessment. Interview with Rehabilitation (Rehab) staff Z on 8/13/15 at 2:20 PM, revealed therapy still did the wheelchair assessments when they got a referral. Rehab staff Z stated the nurses, restorative nurse or anyone can request a wheelchair assessment. Interview with Administrative Nursing staff B on 8/13/15 at 4:55 PM, Administrative Nursing staff B revealed the facility had a fall meeting every week and went over all the falls for the last week. Each discipline is present and decide what further interventions are needed. The staff places a new intervention after each fall. Interview with Licensed Nursing staff C and Administrative Nursing staff K on 8/14/15 at 12:17 PM, revealed direct care staff should do what the nurse tells them to do. The nurse is their supervisor. This staff stated they would look for more information regarding the use of the foot pedals per the current wheelchair assessment. The facility's policy for Fall Prevention Program revealed the purpose was to reduce the patient's risk of falling by improving four categories: environmental, transfer and mobility, equipment, and medications. The facility failed to ensure a footrest was in place for the prevention of falls that resulted in a laceration on the forehead and fractured neck. 2. Resident #566 was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] revealed the resident had short and long term memory problems, and displayed other behavioral symptoms not directed toward others 1 to 3 days of the 7 day observation period. The resident required extensive assistance with bed mobility, transfers, and walking in the room. The resident required extensive assistance with locomotion on the unit, dressing, toilet use, personal hygiene, and bathing. The resident's balance was not steady and only able to stabilize with human assistance when moving from a seated to a standing position, walking, moving on and off the toilet and surface to surface transfers. The activity of turning around did not occur and the resident used a walker and a wheelchair. The resident had not had a fall since the last assessment and the resident received restorative services 7 days of the 7 day observation period. The Care Area Assessment for falls dated 11/18/14 revealed the resident had fall risk factors present including impaired balance, use of psychotropic medications, dementia, and incontinence. The care plan dated 3/24/14 and last updated 1/28/15 listed the interventions: anticipate and meet the resident's needs as much as possible, assess behaviors and try to determine the cause, assess for unsteady gait, assist with hard to manage clothing, fall risk assessment on chart, instruct the resident to call for assistance, keep bed in lowest position, keep environment free of clutter for safety during ambulation, make staff aware of risk for falls, place personal articles and water within easy reach of resident, provide incontinence care after each incontinent episode, monitor adverse effects of psychotropics that affect balance (discontinued on 1/28/15), side rails up to increase the resident's mobility and independence, verbal reminders to the resident to not ambulate alone, safe shoes and slippers while ambulating, ambulate with rolling walker and stand by assist (discontinued on 11/25/14 care plan but with no specific date), new shoes provided by the family, staff to take the resident out of his/her room and supervise when the resident appears to be increasingly agitated, place the resident's wheelchair and walker in the bathroom when the resident is in bed, initiate person centered activity whenever the resident is restless in the wheelchair or he/she attempts to stand, after assessing the resident's need to use the bathroom, fall mats at bedside, sensor alarm, provide option to ambulate with assist during sundowning hours, non-slip pad placed on chair cushion, hourly rounds between hours of 2:00 P.M. and 6:00 A.M. (on 11/25/14 staff discontinued the hours of 2:00 P.M. and 6:00 A.M. and started hourly rounds). On 5/6/14 the staff initiated the intervention to allow the resident to be up at night with supervision if the resident desires, ensure the night light is on while the resident is in bed at night, and prompt toileting before and after meals, mid-afternoon bedtime and at night when awake (discontinued on 1/23/15). Staff on 6/27/14 added new intervention to keep the bathroom door closed when not in use, 7/19/14 - toilet the resident every 2 hours and at bedtime, 12/2/14, staff education on toileting the resident safely with the wheelchair within reach and 2 person assist with all transfers, and 12/27/14 remove the resident from the room in times of agitation. The Post Fall Nursing Assessments revealed the following: a. 6/27/14 and timed 6:38 PM - at 11:00 AM the direct care staff member took the resident to his/her room and then saw the podiatrist coming down the hall and left the resident unattended assuming the podiatrist was going straight to that resident. However the podiatrist actually went to another resident. About 7 minutes later another direct care staff member heard an alarm sounding and ran to the bathroom and found the resident sitting on the floor in front of the toilet. The resident had a skin tear on the right upper extremity on the underside of the elbow. b. 7/19/14 at 8:13 AM - the staff found the resident sitting on the fall matt next to his/her bed holding the pressure alarm box. No injuries noted. c. 11/27/14 at 10:03 AM - revealed that at 7:30 AM the staff heard the alarm sounding and found the resident on the floor on the right side of the bed. No injuries noted. d. 12/2/14 at 2:43 PM - the direct care staff had tried to get the resident out of the bed several times during the shift, but the resident had refused. The resident was finally gotten up around 11:30 AM by the direct care staff. The direct care staff wheeled the resident into the bathroom, assisted the resident into a standing position but right after the staff pulled the wheelchair out the resident tried to side down, the staff assisted the resident to the floor. No injuries noted. e. 12/28/14 at 2:23 PM - a direct care staff member walked in from the outside and heard a fall alarm going off and ran towards the alarm and found the resident sitting on the fall matt by the side of the bed. Staff assisted the resident up and toileted the resident and took him/her outside. No injuries noted. The 1/20/15 Monthly Nursing Summary Report revealed the resident had falls within the last 30 days. The resident was lifted manually, used a manual wheelchair, and lived on the locked Memory Care Unit. The resident wheeled him/herself through the unit and often entered other resident's rooms. The facility's investigation revealed on 1/21/15 at 10:30 PM a direct care staff member found the resident sitting on the side of the bed and the bed alarm sounding. The resident expressed that his/her left shoulder was hurting, but did not give any reason for the pain. On 1/22/15 at 6:30 AM, the nurse was summoned to the resident's room after a nurse aid tried to give morning care. Upon entering the room, the nurse noted there was swelling and pain to the left shoulder and pain isolated to the left hip. The Nurse Practitioner was notified and x-rays were ordered. The left hip x-ray dated 1/22/15 revealed a comminuted impacted left intertrochanteric fracture and the left shoulder x-ray revealed an acute mildly displaced proximal humerus fracture with 5 to 10 millimeters overriding displacement. The direct care staff statement dated 1/21/15 and timed 10:15 PM, revealed while conducting hourly rounds he/she responded to the bed alarm sounding. Upon entering the room the direct care staff discovered the resident sitting on the side of the bed holding his/her left arm and moaning. The resident appeared to be in pain and the resident stated his/her shoulder hurt. The direct care staff noticed the resident's collar bone/shoulder area slightly discolored. The nurse gave Tylenol and the direct care staff applied an ice pack. While performing perineal care the resident presented with signs of discomfort. The Licensed nurse statement stated on 1/21/15 at 10:30 PM, the direct care staff informed this nurse the resident was complaining of pain more then was normal for him/her and the resident would cry out when staff touched his/her arm. The nurse went to the room and the resident complained of pain to his/her left shoulder, left elbow, and left hip. Every time the nurse would touch the resident, the resident would pulled away and say, don't do that, it hurts so bad. Take me to the hospital. It hurts so bad. Staff noted some reddish/purple discoloration around the left collar bone. This nurse reported what happened to the day nurse and that nurse said he/she would follow up. The direct care staff statement dated 1/22/15 revealed the resident was laying in the bed. The direct care staff noticed the resident's left shoulder very swollen and red. The staff continued with the bath and when he/she touched the resident's left leg the resident screamed out in pain. This staff notified the nurse. A licensed nurse statement dated 1/22/14 revealed this staff spoke with the family and the family made the decision to keep the resident at the facility and treat the pain. Interview with Administrative Nursing staff B on 8/13/15 at 4:55 PM, revealed the facility had a fall meeting every week and went over all the falls for the last week. Each discipline is present and decide what further interventions are needed. The staff place a new intervention after each fall. The facility failed to provide supervision for the prevention of a fractured hip and humerus. 3. Resident #313 was admitted on [DATE] with the included [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] for Resident #313 indicated a Brief Interview for Mental Status (BIMS) of 8 indicating moderately cognitively impairment, Resident #313 was not steady, only able to stabilize with staff assistance to move from seated to standing position, was not steady, but able to stabilize without staff assistance to walk (with assistive device if required), not stead, but able to stabilize without staff assistance to turn around, and was not steady, only able to stabilize with staff assistance for surface-to-surface transfer (such as transfer between bed and chair or wheelchair). Resident #313's Complete Patient Care Plan dated 5/28/15 revealed Resident #313's priority number 6 which was safety. Resident #313's safety care plan indicated (Resident #313) has fall risk factors which includes altered mental status, Parkinson's (sic) Disease, Dementia (sic), Lack of Coordination and difficulty is (sic) walking. (He/She) had a history of [REDACTED]. (He/She) attempts to get out of wheelchair unassisted and needs frequent redirections. Resident #313's safety plan indicated the following approaches: Assess for unsteady gait. Assist (him/her) with positioning for comfort. Fall Risk Assessment on chart. Keep (his/him) bed in the lowest position. Keep adaptive devices within reach: wheelchair and walker. (He/She) is to be helped with ADLs prior to breakfast. Do not leave (him/her) in the bathroom unattended as (he/she) will attempt to get up. Reassure needs will be met. Reassure of safety/protection. Redirect (him/her) to sit in regular chair instead of recliner for safety. Increase exercise and walk during therapy. To wear non-skid socks or shoes at all times (dated 4/14/15). Therapy evaluation to be done. (dated 4/19/15) Supervision with ambulation. (dated 4/20/15) Family to notify staff when leaving patient alone. (dated 4/23/15) Remove patient from room during times of agitation. (dated 5/3/15) Bed against the wall. (dated 5/7/15) Pressure Alarm. (dated 5/1/15) 2H (hour) - 3H toileting program. (dated 5/19/15) Toileting every 2 hours at night (dated 5/20/15). Ensure safe environment. Allow patient time to walk with close supervision if (he/she) does not want to sit. If (he/she) becomes anxious and wants to walk, allow (him/her) to walk with close supervision to remove any obstacles from (his/her) pathway. Can walk with SBA (stand by assist) if pathways are clear. Offer (Resident #313) wheelchair before lunch due to fatigued. (added 6/8/15) Family informed to bring no shoes w/ (with) no laces. (added 6/11/15) Family modified that only staff to ambulate pt. (patient) d/t (due to) unsteady gait, loss of balance. (added 6/11/15) Winged mattress (added 6/13/15) Reinstated (medication for Parkinson's disease). (added 7/22/15) . A physician note dated 5/21/15 revealed this patient is seen in the memory care unit. (He/She) has advanced Parkinson's disease and also dementia with Lewy Bodies. (He/She) has fallen about 11 times in the last month and I have spoken with the (Licensed Nursing Staff C) today. There seems to be no pattern regarding (his/her) falls. Reportedly, (he/she) does try to get up in the middle of the night to urinate and (he/she) has fallen about twice in the middle of the night. Fall precautions are in place but the bed alarm causes more agitation so that is not being used but mats are being used. I have spoken with the psych (psychiatric) services nurse practitioner to review (his/her) medications today . The physician's note further revealed I also called the patient's son/daughter, (name), to inform (the family) of the patient's overall condition and my plan and (he/she) agrees that the patient seems to be declining and I think (his/her) falls are probably related to progression of (his/her) Parkinson's disease. Review of internal incident reports submitted for Resident #313's falls indicated Resident #313 had falls with no injuries on the following dates: 5/3/15, 5/7/15, 5/10/15 (2 falls), 5/12/15, 5/19/15, 6/6/15, 6/7/15, 6/11/15 (2 falls), 6/13/15, 6/15/15, 7/22/15 and 7/31/15 (2 falls). Resident #313 had 15 falls between 5/1/15 to 8/1/15 documented on the list. Resident #313 had Physical Therapy (PT) treatments from 12/9/14 to 1/9/15. Physical therapy notes indicated The patient ambulates 700+ (plus) feet on level surfaces requiring hand held assist (hand support only) for safety with hand held physical assist as with initiation cue and verbal, tactile and visual instruction/cues to decrease gt (gait) speed . patient demonstrated . which relates to the medium fall risk category . Patient is able to safely transfer from bed (to) wheelchair requiring hand held assist (hand support only) for safety due to decreased dynamic balance with initiation cue and verbal, tactile and visual instruction/cues for BLE (bilateral lower extremities) sequencing due to decreased motor planning ability during stand-pivot transition . (Resident #313) is able to safely transition from sit (to) stand requiring stand by assistance (close enough to reach patient if assist needed) due to retropulsion (a disorder or locomotion associated with Parkinson's disease marked by a tendency to walk backwards) during initial sit (to) stand with initiation cue and verbal, tactile and visual instruction/cues . for placement and sequencing and proper weight shift more anteriorly during sit (to) stand transition. Pt (patient) also needs verbal and tactile cues to decrease transition speed during stand (to) sit. Resident #313's Physical Therapy Plan of Care evaluation dated 4/21/15 revealed due to the combination of Parkinson's gait with [DIAGNOSES REDACTED], coupled with foot deformities associated with Charcot-Marie Tooth (a genetic disorder characterized by the progressive loss of muscle tissue and touch sensation across various parts of the body) . is too unsafe at this time to benefit from further PT, hoping to reverse his retrograde falls. He is much safer mobilizing in a WC (wheelchair) with alarm, with short ambulatory distances with a CNA (certified nursing assistant) using a safety (gait) belt and hands on assistance only. Record indicated Resident #313 had a PT screening/assessment for annual and indicated his/her last PT assessment and recommendations were still appropriate and to rescreen PRN (as needed). Resident #313 had a PT screening on 6/8/15 which indicated it was for a fall screen. The 6/8/15 PT screening indicated the current FMP (fall management plan) was still appropriate and he/she was functioning at baseline. The PT screening indicated no change per nursing. Recent falls were lowering when fatigued. Direct observation as well as chart review, no skilled intervention required. Observation of Resident #313 on 8/12/15 from 8:11 AM and 12:11 PM, revealed Resident #313 was left unattended in his private restroom. Throughout the observation period, Resident #313 was not wearing a safety (or gait) belt nor was staff observed to assist Resident #313 by use of gait belt. Resident #313 was not observed to have a walker and was not observed to use, have near, or be offered the use of a wheelchair. At 8:11 AM, Resident #313 was seated with a peer in the dining area. At 8:19 AM, Resident #313 continued to be seated with a peer in the dining area and a technician (Tech) / Certified Nursing Assistant (CNA) also sat with the resident. Resident #313 was not observed to be wearing a gait belt. Resident #313 did not have any assistive equipment such as a walker or wheelchair near him/her. At 8:40 AM, Resident #313 ambulated independently without staff assistance to another table to sit with a peer while breakfast was being served. At 9:09 AM, Resident #313 had moved to a lounge chair in the dining area and fell asleep until 9:40 AM. At 9:40 AM, Resident #313 was prompted and physically assisted by Direct Care Staff (DCS) Y with contact assist to join the group seated in the dining room for exercise class. Between 9:53 AM to 10:53 AM, Resident #313 passively participated in the exercise group. At 10:53 AM, Resident #313 had a family member visit him/her. Resident #313 sat at a table with his/her family member while the Recreation Staff G read the newspaper to the activity circle. At 11:52 AM, Resident #313 was no longer seated in the dining area. At 11:53 AM, Resident #313's private bathroom door was shut but the light was on. After a knock on the bathroom door by surveyor, Resident #313 stated Come in but there was no additional staff response. Observations and interview with Licensed Nursing Staff AA (LNS-AA) on 8/12/15 at 11:54 AM, LNS-AA was asked whether Resident #313 was being assisted in the bathroom with staff or whether he/she was left unattended. LNS-AA went into Resident #313's bedroom and opened the bathroom door. At 11:54 AM, Resident #313 was standing upright holding the grab bar nearest the toilet with two hands facing the wall. Resident #313 had his/her adult brief and pants down around his/her mid-thigh area and appeared disoriented. LNS-AA physically prompted him/her to sit back down on the toilet. LNS-AA indicated Resident #313's adult brief was dry. As LNS-AA began to exit the bathroom, Resident #313 stood up again independently using the grab bar with both hands. Resident #313 had arm and hand tremors while holding the grab bar. LNS-AA physically prompted Resident #313 to sit back down on the toilet which he/she did. LNS-AA exited the bathroom leaving Resident #313 unattended and closed the door. Interview with LNS-AA indicated Resident #313 did not come into his/her bedroom unattended. LNS-AA indicated he/she saw Resident #313 standing in front of his/her bedroom door alone so he/she assisted him/her to be seated in the lounge chair in his/her room. LNS-AA indicated he/she thought he/she was assisted after breakfast and stated they try to keep an eye on (him/her). LNS-AA stated the facility can't use any type of alarm for Resident #313 because it startles him/her and increased his/her risk for falls. LNS-AA left the bedroom and asked a Tech to assist Resident #313. The Tech assisted Resident #313 in the bathroom and walked out of the bedroom with him/her using contact assist with the left arm and elbow. Resident #313 was wearing his/her gait belt and his/her wheelchair was observed to be left in the shower stall of the bathroom. Interview with the Licensed Nursing Staff (LNS-C) on 8/10/15 at 1:12 PM, LNS-C revealed Resident #313 walked independently down the hall without staff. Resident #313 was not wearing a gait belt or using any other assistive equipment. LNS-C indicated Resident #313 had made improvements in his/her ambulation since beginning a new medication for his/her [DIAGNOSES REDACTED]. Interview with Licensed Nursing Staff C (LNS-C) on 8/12/15 at 4:59 PM, LNS-C revealed Resident #313's fall care plan (safety plan) had not been updated since 8/2/15 when nightly prompting to use the restroom was discontinued. LNS-C indicated he/she was unaware Resident #313 was in the bathroom unattended during the 8/12/15 observation period. The LNS-C stated, Yes, it looks like the care plan has Resident #313 is to use hand to hand assist. The LNS-C revealed the care plan indicated Resident #313 used an alarm while in bed but it had been discontinued. The LNS-C revealed they initiated the use of the bed alarm again because of what they were seeing. The LNS-C indicated Resident #313 should be reminded to use the restroom every 2 hours and 2 hour prompting also overnight. Interview with LNS-C, Licensed Nursing Staff BB (LNS-BB), and Rehabilitation Staff Z (RT-Z), on 8/13/15 at 2:11 PM, LNS-C, LNS-BB, and RT-Z, revealed a multi-disciplinary team meet each Monday to review falls, review care plans, and revised them as necessary. The RT-Z indicated Resident #313 should not have been in the restroom unsupervised as indicated in his/her fall care plan. The RT-Z indicated according to Resident #313's physical therapy notes, he/she required contact guard at minimum, not able to get up from sit to stand without moving backward, continue to move about in (his/her) wheelchair with cushion supplied and alarm, to and from short distances with a gait belt as (he/she) stumbles frequently as (he/she) requires contact assistance. The RT-Z indicated she has observed him go place to place and (he/she)'s been safe without assistance. The RT-Z was asked whether the PT recommended use of gait belt was in Resident #313's care plan. RT-Z reviewed the care plan and stated he/she did not see it on those two pages. LNS-BB revealed the use of gait belt might have been in a therapy care plan but upon review was unable to locate the indication for use of gait belt. LNS-C revealed Resident #313 had improved a great deal since beginning a new medication for Parkinson's disease and his/her improvement might not have been reflected in the care plan in regards to adequate supervision. No further documentation was available for review to indicated the staff provided the necessary and recommended level of supervision and assistance of Resident #313 to prevent recurrence of falls. The facility's policy for Fall Prevention Program revealed the purpose was to reduce the patient's risk of falling by improving four categories: environmental, transfer and mobility, equipment, and medications.