Every finding on record at Northern Montana Care Center

Based on interview and record review, the facility failed to administer an influenza vaccine for 1 (#12) of 5 sampled residents for vaccinations. Findings include:Review of the vaccination consent/declination form, signed on 10/31/25, showed resident #12's POA consented to receiving the influenza vaccine.During an interview on 7/18/26 at 8:06 a.m., staff members A and C stated resident #12 did not have documentation of receiving an influenza vaccine the resident consented to on admission. Staff member C stated she had not been working at the time. Staff member A stated the consent was found in the paper completed filings, but the resident's medical record did not show an actual administration of the vaccine.Review of resident #12's EHR on 7/16/26, did not show an actual administration of the influenza vaccine on admission. The facility had no evidence the vaccine was provided to the resident.

Based on observation, interview, and record review, the facility failed to complete a Discharge Minimum Data Set Assessment for a resident who passed away in the facility for 1 (#67) of 24 sampled and supplemental residents. Findings include: Review of resident #67's discharge summary with a date of 2/20/26 showed: . Narrative: Patient passed peacefully with her family by her side.Review of resident #67's electronic medical record showed:Minimum Data Set Assessment list: Tracking entry MDS with an accepted date of 2/12/26 had been completed.Comprehensive MDS with an accepted date of 2/19/26 had been completed.The electronic medical record failed to show that a Tracking (Death record) MDS had been completed after resident #67 passed away. During an observation and interview, on 7/15/26 at 4:12 p.m., staff member G was on her computer and looked up resident #67's MDS records. Staff member G stated she could see the entry MDS had been done on 2/5/26 and stated, That was her Assessment Reference Date. Staff member G stated resident #67's Comprehensive admission MDS was completed on 2/14/26. Staff member G stated resident #67 passed away in the facility on 2/20/26, and a death in facility MDS had not been completed. Staff member G stated her process for completing MDS assessments was to submit MDS submissions every Thursday after staff completed their IDT review meeting. Staff member G stated, I just missed this one, and I don't know why. Staff member G stated, I will get it submitted right now. The Death in Facility Discharge MDS was 118 days late. Review of a facility document titled Minimum Data Set (MDS) with a revision date of 6/16/25 showed: Policy: The Resident Care Coordinator/designee shall complete assessments of all residents at the Care Center using the Resident Assessment Instrument (RAI) format.Purpose: To ensure that the RAI is used in conducting comprehensive assessments as part of an ongoing process through which the facility identified the resident's functional capacity and health status.3. Information needed to complete MDS/CAA/[NAME] can be obtained from any pertinent assessment/intervention in resident record, or interview of resident, family, or providers.

Based on interview and record review, the facility failed to document required information for resident transfers/discharges for 2 (#s 76 and 78) of 21 sampled residents and failed to inform the Ombudsman's office of all resident transfers/discharges. Findings include: During an interview on 7/15/26 at 4:17 p.m., staff member F stated that when a resident would go on LOA or transfer to another facility, the floor nurse would fill out the same form for a transfer and/or bed hold and then mark the reason for leaving. The nurse would then fax the form to the admission department to hold the resident's chart. Staff member F stated the nurses were to have medications repackaged by the pharmacy for the LOA residents, but they did not document in the medical record information regarding the LOA or transfer. Once they (residents/chart) were placed on a hold, the nursing staff did not follow up unless the resident returned. Staff member F stated no documentation or assessment would be completed for a resident returning from LOA unless a resident specifically told them they had an issue while on LOA, and the resident returned any medications to be placed back in the medication cart.During an interview on 7/16/26 at 10:08 a.m., staff member A stated resident #76 had a bed hold in place as he wasn't admitted to another nursing home and he didn't discharge to his home. Staff member A stated resident #76 had no family, so it was a way to keep his belongings safe in case he returned to the facility. Staff member A stated even though resident #76 had been gone for over 40 days, he would have missed the time to complete a 30-day discharge notice since the resident was a bed hold until he left the hospital. Staff member A stated they would continue the bed hold as the facility had plenty of rooms available for a return. Staff member A stated that for a LOA such as with resident #78, there was no expectation for facility staff to document on the resident, as the form that was filled out showed they were out of the facility and their EHR would show the LOA warning if they tried to open it. Staff member A stated the facility charted by exception but had a process with the forms so nursing would not document for a LOA or bed hold. During an interview on 7/16/26 at 10:16 a.m., staff member D stated the facility EHR system placed resident #76 on LOA because the medical record did not differentiate between LOA and bed holds. There would be documentation showing 'hospital,' reflecting it was not a therapeutic LOA, or a LOA for resident #78 completing a trial stay at home. Staff member D stated resident #78 was private pay, and she didn't have a qualifying stay for Medicare A services. Staff member D stated resident #78's POA wanted the resident to have a trial stay at home before discharging just to make sure she was ready. If it went well, they would discharge after, and she discharged the same day she returned from LOA.Review of resident #76's EHR between 7/13/26 and 7/16/26, including the census, facility progress notes, and provider notes, showed the resident was admitted to the facility on [DATE] and transferred to the emergency department on 6/9/26. He was then transferred from the emergency room to another hospital on 6/10/26, admitted to that hospital, where he remained as of 7/16/26. Resident #76's chart did not have documentation of an indefinite transfer or bed hold, or a recapitulation of stay, after 30 days out of the facility.Review of resident #76's census showed: Enter ADM Skilled Nursing Facility on 6/3/26, Enter LOA on 6/9/26 with the note of Hospital, Change Room/Bed on 7/1/26. Review of resident #78's facility progress notes, dated 5/6/26 to 5/12/26, showed her POA communicated to staff member D on 5/6/26 that they wanted the resident to have a trial weekend at home before discharging. Resident #78 was placed on LOA status on 5/8/26 and returned from LOA on 5/12/26 to discharge on [DATE]. Resident #78's family member communicated to the facility that she wanted resident #78 to be discharged on 5/11/26, and the facility communicated the provider was not available and would write a physician's order for the resident to discharge on [DATE]. Resident #78's progress notes did not include documentation of the required information for a discharge from the facility.During an interview on 7/15/26 at 2:20 p.m., NF1 stated the Ombudsman's office received no regular transfer or discharge notices for residents staying at the facility unless there was an involuntary discharge.Review of resident #78's medical record, under the census, showed: Enter admin Skilled Nursing Facility on 4/16/26, Enter LOA on 5/8/26 with a note of Home, End LOA on 5/12/26 at 12:30 p.m. with a note of Home; and, Discharge Skilled Nursing Facility on 5/12/26 at 12:30 p.m.Review of resident #78's medical record face sheet showed the payor source as Medicare AB and private insurance.Review of resident #78's form titled Financial Responsibility Statement, signed 4/16/26, showed the payor source selected was the resident's own financial resources and long-term care insurance.Review of the facility policy titled Bed-Hold Notice/Discharge/Readmit/Transfer, last reviewed 6/13/25, showed: . C. Nursing staff shall document the reason for a transfer and notify the family of the transfer. Resident's Temporary Hospitalization.G. [Facility] shall maintain, and upon request, provide to the State, documentation that the absence is expected to be temporary and the anticipated duration of the absence.Temporary absences of indefinite duration must be documented at least weekly by nursing or a physician to assure that the absence is indeed temporary.Review of the facility policy titled, Interdisciplinary Discharge Process, last reviewed 6/13/25, showed: .5. Interdisciplinary Discharge plan shall include the following:. e. instructions. pertinent information regarding individual diagnosis.6. [Facility] shall complete a summary of information about the resident upon discharge to home or other community-based service. This shall provide continuity of care to the resident & responsible, authorized parties. The interdisciplinary discharge summary shall be documented in Meditech. Each respective discipline shall access the Discharge Summary to document in prospective areas.3. The nurse is responsible for entering information into the Discharge Summary.4. When a potential discharge date or time has been identified, the social worker or designee shall contact the provider and notify him or her of the potential for discharge. The provider may choose to see the resident prior to his/her going home.10. The Discharge Packet shall be reviewed with the resident/designee. The signatures of the resident/designee and of the nurse reviewing the plan are required. Place the signed copy in the chart and send a copy with the resident as discharge instructions.11. A copy of the Discharge Packet shall be given to the resident/designee along with his or her packaged medication(s) and any special equipment received upon discharge.12. The discharging nurse shall enter a note giving the date and time of discharge accompanied by the method of discharge (i.e., ambulatory, by wheelchair or by stretcher). [Facility] shall complete a summary of information.2. The summary shall be complete prior to or on the day of discharge.

Based on observation, interview, and record review, the facility failed to ensure 1 (#57) of 30 sampled residents were safe from wandering the facility and into 4 other residents' rooms (#s 7, 31, 41, and 64). This deficient practice increased the risk of negative interactions between the residents related to safety and infection control concerns. Findings include: During an interview on 6/28/25 at 3:38 p.m., resident #64 stated resident #57 was often confused and would wander into his room, sometimes at night. Resident #64 stated he did have a history of PTSD, and resident #57 walking into his room made him feel uncomfortable. Resident #64 stated resident #57 would sometimes steal things from his room. Resident #64 stated he was told by staff to put his items away when he left his room to prevent resident #57 from taking any of his items. During an observation on 6/29/25 at 3:21 p.m., resident #57 was in her wheelchair, and she wheeled into resident #7's room when the resident was sleeping. Resident #57 watched resident #7 for approximately 30 seconds, then exited the room. During an observation on 6/29/25 at 3:24 p.m., resident #57 wheeled her wheelchair into resident #41's room. Resident #57 touched resident #41's chair and the leg rests located on the wheelchair. During an observation on 6/29/25 at 3:25 p.m., resident #57 wheeled her wheelchair into resident #31's room and touched resident #31's shoes. During an interview on 6/29/25 at 3:45 p.m., staff member F stated resident #57 was able to move throughout the entire facility, and the staff relied on the wanderguard to ensure her safety. Staff member F stated it was not a concern that resident #57 was in other resident's rooms, other than resident #64, as he expressed this bothered him. Staff member F stated resident #57 had gone through another resident's closet before as well as wandering into other resident rooms. Staff member F stated there could be a concern for infection control with resident #57 wandering into so many resident's rooms. Review of a facility policy titled, Wandering Behavior with Usage of the RoamAlert System, revised 3/19, showed: . 3. Determine when wandering requires interventions to reduce unwanted intrusions on other residents. [sic]

Based on interview and record review, the facility failed to update individualized resident care plans regarding behaviors and previous trauma, for 2 (#s 61 and 64) of 30 sampled residents. This deficient practice increased the risk for #61 and #64 not having preferences met or known, and a resident's exhibited behaviors continuing without interventions being implemented. Findings include: During an interview on 6/29/25 at 3:49 p.m., staff member F stated resident #61 and resident #64 would have some outbursts or display behaviors at times. Staff member F stated the facility had behavior charting when those events occurred. a. Review of resident #61's EHR showed a nursing note, dated 6/28/25, which showed, Resident was in dining room for breakfast when another resident yelled out then she (resident #61) proceeded to yell at that resident to Shut up and cursing at that resident. then resident was cursing at staff and came out and told this nurse im gonna knock [name] on her ass one day. and continued fussing and curing (cursing) while going to her room. [sic] Review of Resident #61's individualized care plan, last reviewed 4/17/25, showed no mention of a problem, goal, or interventions regarding resident #61's outbursts and verbal behaviors towards other residents or staff. b. Review of resident #64's EHR showed PTSD as a diagnosis. Review of resident #64's individualized care plan, last revised 6/5/25, showed there was no problem, goal, or nonpharmacological interventions identified and documented to be utilized by staff regarding resident #64's PTSD. During an interview on 6/30/25 at 9:05 a.m., staff member A and C stated the staff were doing interventions daily regarding resident #61's behaviors and resident #64's PTSD, but stated the facility could be better about taking credit for those interventions and documenting them.

Based on interview and record review, the facility failed to ensure a PASARR was completed for 1 (#64) of 30 sampled residents. This deficient practice increased the risk of the resident not being assessed or receiving necessary services related to the resident's mental health diagnosis or PTSD. Findings include: During an interview on 6/28/25 at 3:38 p.m., resident #64 stated he had PTSD from the war. Review of resident #64's EHR showed a diagnosis of PTSD. A request was made on 6/29/25 at 11:57 a.m., for resident #64's Level I and Level II PASARR. During an interview on 6/29/25 at 2:03 p.m., staff member C stated the facility did not have a PASARR for resident #64. Staff member C and staff member A stated they worked with [Entity Name] who filed most of their paperwork, and resident #64's PASARR must have gotten lost in the transfer to [Entity Name].

Based on observation, interview, and record review, the facility failed to ensure there was a physician order and consent signed on in the EHR for a physical restraint, which was a seatbelt used for a resident who used a motorized wheelchair to assist with preventing falls, for 1 (#50) of 30 sampled residents. Findings include: During an observation on 6/28/25 at 5:26 p.m., resident #50 had a seatbelt on while he was sitting in his motorized wheelchair. Review of resident #50's EHR showed no consent or physician order was present for the seatbelt, which restrained the resident, in his motorized wheelchair. Review of resident #50's EHR showed a physician's note, dated 9/6/24, which showed the following diagnoses: bipolar I disorder, intellectual disability, developmental delay, PTSD, hypertension, insomnia, prediabetes, traumatic brain injury, history of institutionalization, aggressive behavior, difficulty with speech, on a combination of antipsychotic drug therapy, and a history of a sacral pressure ulcer. During an interview on 6/30/25 at 8:52 a.m., staff member E stated they were unaware a physician's order and a consent was needed for a seatbelt, which was used to help prevent the resident from falling, but they would fix the concern quickly. A review of #50's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 5/21/25, showed the resident was not able to complete the Brief Interview for Mental Status. He was coded as having inattention and disorganized thinking. He had both upper and lower extremity deficits, and was dependent for mobility. The resident was not coded as using a restraint. During an interview on 6/30/25 at 9:05 a.m., staff members A and C stated they had not considered a seatbelt on a motorized wheelchair to be a restraint. Staff member A stated they now realized how it could be used as a restraint, especially with a resident with a lower cognitive ability. Staff member A and C stated it was a requirement that physical therapy do an assessment with the resident, which was not completed for the seatbelt resident #50 had on the chair. Review of a facility policy titled, Restraint Policy, last revised, 4/2020, showed: - It is the policy of the [Entity Name] to prohibit the use of restraints, safety devices and postural supports, except when used to treat a resident's medical symptoms. - Restraint: Any method (chemical or physical) of restricting a person's freedom of movement that prevents independent and purposeful movement. This includes . controlling physical actvity . - Safety device: . the definition of a safety device to be an applicance used to maximize the independence and the maintenance of health and safety of an individual by reducing the risk of falls and injuries associated with the resident's medical symptoms. - No restraint of any kind may be employed unless the order for one has been signed by the LTC Administrator, LTC Director of Nursing, and LTC Director of Social Services.

Based on observation, interview, and record review, staff member G failed to adhere to proper infection control practices related to performing hand hygiene prior to donning gloves and after doffing gloves for 3 (#s 13, 37, and 179) of 5 sampled residents observed for medication administration. Findings include: During an observation on 7/31/24 at 7:28 a.m., staff member G sanitized her hands and donned gloves to administer eye drops to resident #37. Staff member G administered the eye drops to resident #37, then doffed her gloves. Staff member G did not perform hand sanitization after she doffed her gloves or before she donned a new pair of gloves to perform blood glucose monitoring for resident #37. During an observation on 7/31/24 at 7:32 a.m., staff member G administered resident #179's morning medication. Staff member G prepared blood glucose monitoring supplies for resident #179, then donned gloves. Staff member G did not perform hand sanitization prior to donning the gloves. During an observation on 7/31/24 at 7:44 a.m., staff member G gathered supplies to perform blood glucose monitoring for resident #13. Staff member G donned gloves but failed to perform hand sanitization prior to donning the gloves. During an interview on 7/31/24 at 8:07 a.m., staff member G stated hands should be sanitized before and after each glove change. She stated hands should also be sanitized before and after each resident contact or administration of medications. Staff member G stated she had missed hand sanitization a few times during her medication pass. During an interview on 7/31/24 at 8:55 a.m., staff member C stated hand sanitization should be performed prior to donning gloves and after doffing gloves. She stated hand sanitization should be performed before and after each resident contact. Review of the facility's document titled, Hand Hygiene, last revised 4/24, showed: - . If hands are not visibly soiled, an alcohol-based hand sanitizer may be used for routinely decontaminating hands in the following clinical situations: - Before having direct contact with patients. and - After removing gloves.

Based on observation, interview, and record review, the facility failed to ensure dignity and respect were honored for privacy of medical information, for 1 (#1) of 6 sampled residents. This deficient practice had the potential to affect all residents who were provided incontinence care by facility staff. Findings include: During an interview on 3/23/24 at 11:27 a.m., NF1 stated she had received a call from NF2 with allegations of abuse and neglect. NF1 stated NF2 was upset because resident #1 had her pubic area shaved while she was provided incontinent care by staff members. During an interview on 3/25/24 at 11:50 a.m., NF2 stated resident #1 had dementia and had very poor short and long-term memory loss. NF2 stated she was made aware of the incident, of the resident being shaved, by staff on 3/8/24 when she had come to the facility to visit resident #1. NF2 stated she had asked nursing staff about bruising that was noted to resident #1's arm. NF2 stated she was told the bruising was from a lab draw that morning. NF2 stated, That is when I found out that resident #1 had her pubic region shaved by two CNAs. NF2 stated she went back to resident #1's room and checked the resident's pubic region. NF2 stated she had not noticed any bruising on resident #1's legs or thighs, but I did not check her as close as I wish I would have. NF2 stated, I am very upset with her care. The facility is acting like what happened to resident #1 is ok. I know resident #1, and she would not have allowed this to happen. NF2 stated she called NF1 and staff member C and let them know I had called NF1. NF2 stated, I am very angry about this. Why would anyone do this to an elderly person? NF2 stated she had also called and spoke with NF3, a nurse at the clinic on 3/12/24. NF2 stated, I had asked her if resident #1 needed a rape exam. NF2 stated after she had talked to NF3 she had also talked to staff member L. NF2 stated, Staff member L told her a gynecological exam would be very hard on resident #1, and the exam would have to be done under anesthesia. NF2 stated she told staff member L she did not want the exam done at that time. NF2 stated the facility has a video of the time this happened, and they will not allow me to view it. NF2 stated she had attended a care conference in January of 2024 regarding resident #1. NF2 stated, During the care conference I had told staff member C I preferred to have female caregivers for resident #1, but there were a few male CNAs that were ok to provide care to resident #1. Review of a facility video on 3/25/24 at 11:42 a.m., showed staff member E walked into resident #1's room and walked back out. Staff member E started to walk down the hallway, and appeared to be looking for resident #1. At 11:47 a.m., resident #1 was walked back to her room by staff members E and H. At 11:56 a.m., staff member E walked out of resident #1's room and returned at 11:56 a.m., with shaving cream and a razor. At 12:09 p.m., staff member M opened the door slightly and looked inside the room. At 12:11 p.m., staff member D opened the door to resident #1's room and went inside. At 12:13 p.m., staff member D exited resident #1's room with resident #1 and walked down the hallway. During an observation and interview on 3/25/24 at 12:40 p.m., resident #1 could not answer questions appropriately and walked back out of her room. Staff member F walked resident #1 back to her room and attempted to assist her with lunch. During an interview on 3/25/24 at 1:30 p.m., staff member B stated the expectation for staff was to talk with the charge nurse on shift if there was anything that happened out of the ordinary, or if a resident needed a different level or type, of care. Staff member B stated, I don't know what was going through their heads (staff who shaved the resident), but I definitely do not feel it was malicious at all. During an interview on 3/25/24 at 1:57 p.m., staff member C stated staff members E and H were not suspended after the incident. Staff member C stated, I am not sure why we did not suspend them other than we (administration) felt this was a care issue and not a reportable incident. I spoke with both staff members, and they explained what had happened. I know that when staff member A received a call from NF3 with the concerns NF2 verbalized, we started an investigation immediately. We called and spoke to the police department as well. During an interview on 3/25/24 at 2:28 p.m., staff member D stated she was the charge nurse on 3/5/24. Staff member D stated, I did not know what had happened until afterwards. I was breathless. I tried to call staff members A, B, and C for guidance but never got any response from them. I should have called family, but I didn't. During an interview on 3/25/24 at 2:45 p.m., staff member E stated staff member D told them (the CNAs) it was time to check and change resident #1. Staff member E stated, Resident #1 was not in her room, but we had found her and took her to her room to be changed. Staff member H was working on a different unit, but offered to help me because the other CNAs were still looking for resident #1 and had not come back to the unit yet and resident #1 smelled bad and needed to be cleaned up. We laid resident down on her bed and found that she was wet and had very thick BM all over. Staff member H took some wet washcloths and started to clean her up. Resident #1 was calm at this time. Resident #1 became upset when we tried to clean her peri-area. Resident #1 had said 'ouch'. Staff member H stopped cleaning resident #1 at that time so he did not hurt her, he asked me to go and get some shaving cream. We put the shaving cream on resident #1's peri-area and let it sit there, hoping it would loosen up the BM. The shaving cream did not help so staff member H started to shave the BM out of her (the resident's) pubic hair. I told staff member H we should check with the nurse, but he did not stop shaving her, and I did not leave to go get the nurse. When we were almost done the nurse came into the room to see what was taking so long and that is when I told her what was done. She looked at resident #1's peri-area, then walked with resident #1 out of the room. A call was placed to staff member H on 3/25/24 at 2:59 p.m., A message was left with the State Surveyor's call back information. The staff member returned the call at 6:04 p.m. During an interview on 3/25/24 at 6:04 p.m., Staff member H stated, Me and staff member E ended up shaving resident #1. Resident #1 wanders a lot, and we were trying to locate her. When we found her, she smelled bad. We took her back to her room to clean her up. She was wet and covered in thick BM. I tried to clean her using wet washcloths but that did not work. We shaved the BM out of her pubic hair. The resident was calm while we were cleaning her up. I let the nurse know after we shaved her. I did not think this would be such a big deal. We were just trying to clean her up with out hurting her. I really thought we were doing the right thing. During an interview on 3/26/24 at 7:15 a.m., staff member A stated he reported the incident to the State Survey Agency as soon as he had gotten off the phone with NF3 and was made aware of the allegations NF2 made. Staff member A stated, Staff member C and I started an investigation right away and reported the incident to the police department, started interviewing residents, and interviewed staff. Staff member A stated, I am not sure what they were thinking, they absolutely did it backwards. They truly believe that what they did was helping the resident. I do not believe what they did was malicious or showed any willful harm to the resident. Every staff member has been educated on dignity, incident reporting, and abuse and neglect, since this incident occurred. Resident #1 is now to be cared for by female staff only. During an observation on 3/26/24 at 9:20 a.m., resident #1 was toileted by staff members G and J. Peri-care was performed. Resident #1's peri-area was not red. The pubic area was shaved in the upper part of the pubis region and showed hair growth. Resident #1's pants were pulled into place and resident #1 began to scratch at her peri-area and stated it itched. During an interview on 3/26/24 at 9:45 a.m., staff member I stated he used to provide care for resident #1. Staff member I stated, Resident #1 does not understand what cares are being done. Sometimes she would let me provide care for her and other times she would not. I was told by NF2 that it was ok to still care for resident #1 because she liked me. I do not provide any care to resident #1 since she is now female only caregivers. During an interview on 3/26/24 at 9:57 a.m., NF4 stated she was also looking into the incident involving resident #1. NF4 stated she had spoken to NF2 and spent some time with resident #1. NF4 stated resident #1 would not engage with her and her investigation is not complete at this time. During an interview on 3/26/24 at 12:35 p.m., Staff member L stated, I had been made aware of the situation involving resident #1 and had cared for resident #1 for many years. I had spoken to NF2 after she had called and spoke to NF3 about the incident. NF2 asked about the need for a rape kit. I explained in great detail that it was not a good idea because it would be very traumatic for resident #1. I explained the exam would have to take place under anesthesia and with team of OB/GYN doctors. I did not refuse to examine her, I just explained how traumatic physically and emotionally it would be for her. I honestly thought the family was ok with the solutions that were implemented. It surprises me it has gone this far. Resident #1 has been stable and there had not been a change in her baseline behavior. The family fixates on certain things or medical tests or demand an unrealistic expectation of care. I do not think this was meant to harm resident #1. During an interview on 3/26/24 at 2:32 p.m., NF3 stated she had received a phone call from NF2 on 3/12/24. NF3 stated NF2 expressed that she did not know who to talk to about the incident that had occurred. NF3 stated, I explained to NF2 that I was not part of administration for long term care, but I let her finish ranting. NF2 kept asking questions about the incident that I could not answer. I had encouraged NF2 to call and speak with staff members A, B, and C, about her ongoing concerns. After I had got off of the phone with NF2, I called and spoke to staff member A about the concerns. A review of staff member E's new hire paperwork, dated 8/31/22, and Staff member H's new hire paperwork, dated 5/10/23, showed: Staff members E and H been educated and passed Relias training regarding abuse/neglect, resident care, and resident rights. Staff members E and H signed an acknowledgement of resident's rights. A review of a facility document titled, Quality of Care Expectations, with a reviewed date of 1/2024, showed: . C. Dignity and Respect. 1. The resident's private space and property shall be respected at all times. . I. Psychosocial 6. Staff shall recognize psychosocial needs including the following: a. Dignity.

Based on observation, interview, and record review, the facility staff failed to remove expired items for disposal for two out of four medication rooms. Findings include: During an observation on 8/2/23 at 8:47 a.m., the following were found in medication room number one: - 1 green tip culture swab with an expiration date of 10/31/21, - 1 red tip culture swab with an expiration date of 12/31/22, - 1 blue tip culture swab with an expiration date of 3/22/23, - 3, 30 gauge, half inch syringes with an expiration date of 5/28/22, -Cavilon barrier film with an expiration date of 07/22, and -1 vial of open PPD solution, with no open or discard date. During an interview on 8/2/23 at 8:50 a.m., staff member E stated the medication aides go through the medication rooms and get rid of the expired medications and supplies. Staff member E stated she was unsure how often the medication room should have been gone through, but thought it was done weekly, on Sundays. During an interview on 8/2/23 at 8:59 a.m., staff member C stated, Medication carts and medication rooms are to be checked monthly for expired medications and supplies by nursing staff. The standard of practice is to always check expiration dates (of medications or supplies) prior to use. During an observation on 8/2/23 at 9:00 a.m., a review of the number three medication room showed: - 12 packs of cotton tipped applicators with an expiration date of 7/8/20, - 3 surgical lubrication packets with an expiration date of 3/31/22, - 1 kangaroo flush bag for a tube feeding, with an expiration date of 7/31/22, - skin prep wipes with an expiration date of 9/21 and 7/22, and - 2 polysporin ointment packs with an expiration date of 7/23. During an interview on 8/2/23 at 3:20 p.m., staff member A stated, There is no policy for the expired supplies. A policy is currently being written. A review of a facility policy, titled, Administration, Storage, Requisition and Preparation of Medications at [Facility Name], with a review date of 7/2023, showed: .2. Multi-dose Vials a. An uncontaminated/unopened multi-dose vial may be used until the manufacturer's expiration date if stored as recommended. All open MDVs shall be labeled with a sticker noting the date of the first use and shall be considered expired 28 days after the initial opening.

Based on interview and record review, the facility failed to ensure pneumococcal vaccine declinations and education were provided and signed for 2 (#s 12 and 46) of 5 sampled residents. Findings include: Review of resident #12's EMR showed the resident had not received the PCV15 or PCV20 pnuemococcal vaccines, which she was due for. There were no declinations or education for the vaccine documented in the resident's chart. Review of resident #46's EMR showed the resident did not have documentation of receiving a pneumococcal vaccine. There were no declinations or education for the vaccine in the resident's chart. During an interview on 8/2/23 at 2:04 p.m., staff members A and C stated they did not have the pneumococcal vaccine declination for resident #12, and would keep looking. Staff members A and C stated the pneumococcal vaccine was not offered yearly to resident's who declined previously. Staff member C stated vaccines were reviewed upon admit, and consents and declinations for vaccines should have been signed then. During an interview on 8/2/23 at 3:39 p.m., staff member C stated she could not find the pneumococcal declinations for resident #s 12 and 46, and would have to call their families to get a new consent or declination. A review of the facility's policy, Influenza/Pneumococcal Vaccination, dated 4/2023, showed, .All eligible patients shall be offered pneumococcal vaccination .

Based on interview and record review, the facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days for 3 (#s 4, 9, and 41) of 5 sampled residents. Findings include: During a phone interview on 8/31/22 at 9:24 a.m., NF2 stated the facility providers did not want the pharmacy to put in a stop date for PRN psychotropic medications because they wanted control over when the medications were discontinued. The pharmacy was told to document when a PRN psychotropic medication order was due to be reviewed and nursing would notify the provider to either get the order discontinued or changed. NF2 stated a stop date should be put in by the pharmacy. During an interview on 8/31/22 at 3:03 p.m., staff member C stated the provider did not put in a review date or stop date for the PRN Ativan for resident #s 4 and 9. 1. A review of resident #4's current orders in the EHR, showed, Lorazepam 1 mg tab PO Q4H PRN, with a start date of 6/22/22. A review of a facility document titled, Care Center Patient Pharmacy Record Review, for resident #4, showed two handwritten entries as, Missing specified duration of PRN Ativan per CMS regulations . signed by the pharmacist and dated 7/14/22 and 8/3/22. 2. A review of resident #9's current orders in the EHR, showed, Lorazepam 0.5 mg Q4H PRN, with a start date of 6/12/22. A review of a facility document titled, Care Center Patient Pharmacy Record Review, for resident #9, showed two handwritten entries as, Missing specified duration of PRN Ativan per CMS regulations . signed by the pharmacist and dated 7/14/22 and 8/3/22. 45447 During an interview on 8/31/22 at 10:28 a.m., staff member B stated prn psychotropic medications had to be renewed every two weeks, and staff member F handled the communication to the providers for the renewal. 3. During an interview on 8/31/22 at 10:46 a.m., staff members C and F stated there was a prn psychotropic medication monitoring spreadsheet used to track when medication renewals were due. Staff member C stated before the 14th day, a message was sent to the ordering provider to evaluate the continued need for the prn medication. Staff member C stated the providers responded with what action they decided, but the providers did not put the duration of the medication to be used. Staff member C stated a duration was not indicated on resident #41's prn orders because a message was always sent before the two weeks were up. During an interview on 8/31/22 at 10:57 a.m., staff member C stated the physicians were not responding to the pharmacist's medication review recommendations with the requested wording for the duration of the prn medication ordered, which was why there were repeated requests for a duration on resident #41's pharmacy record review. Staff member C stated she was unsure what the facility policy said about what was needed to continue a prn psychotropic medication per the CMS regulations. Review of resident #41's EHR showed medication orders, with a start date of 6/25/20, LORazepam 1 MG TAB 1 mg PO Q4H PRN. Review of resident #41's EHR showed medication orders, with a start date of 12/9/20, Lorazepam 2mg/ml Inj 2 mg IM TID PRN. Review of resident #41's medication renewal notification, written by staff member J, dated 3/3/22, reflected, .Lorazepam 2 mg/ml Inj 2 mg IM TID PRN and Lorazepam 1MG PO Q4HR PRN Reviewed. Continue Lorazepam PRN as ordered. There was no duration indicated for the medication to be given. Review of resident #41's Care Center patient Pharmacy Record Review for staff member I, dated January 2022-August 2022, reflected the following from the pharmacist on 2/7/22, 3/7/22, 4/5/22, 5/6/22, 6/8/22, 7/12/22, and 8/9/22, Missing specified duration of therapy for prn Ativan per CMS regulations. A review of the facility's policy, Psychopharmacological Medication, reviewed 6/2022, reflected: C. PRN orders can be written both oral (PO) and intramuscular (IM). ii. Physician shall need to review a need for continued psychotropic medications after 14 days. Required Actions: Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration.

Based on interview and record review, the facility failed to notify residents of the right to file a grievance anonymously, receive a written copy of the grievance outcome, failed to provide the contact information for the grievance official, for 1 (#43) of 2 sampled and supplemental residents; and, failed to ensure the facility's grievance policy contained the required information related to grievances. Findings include: During an interview on 8/30/21 at 9:34 a.m., resident #43 stated she went to the Resident Council meeting several weeks ago and complained about her menu.When asked how the complaint was handled, resident #43 stated her menu was changing slowly, but that no one had come to talk to her about it. When asked, resident #43 stated she was not aware she could submit a grievance anonymously, and had never been offered a written copy of the resolution of her menu grievance. During an interview on 8/30/21 at 10:03 a.m., staff member B stated, everyone knows to go to staff member D for complaints or concerns. Staff member B stated an admission a letter was sent to all new admissions and their families which identified staff member D as the person who should be contacted with complaints or concerns. Staff member B stated the facility did not have a mechanism for submitting written or anonymous grievances. During an interview on 8/30/21 at 2:40 p.m., staff member D stated she was responsible for handling resident complaints. Staff member D stated when a resident had voiced a concern during resident council, it went to the department head related to the concern. If the department head was not at the meeting, staff member D would forward the details of the complaint via email to the appropriate department head. Staff member D stated there were no grievance forms available for a resident to submit a grievance in writing or anonymously. A review of the form letter from staff member B which was sent to all new admissions, not dated, showed the following: As a resident of the [facility name], <<First_Name>> is entitled to resident rights, . If at any time you have a concern or you do not feel you or <<First_Name>> is being listened to, I encourage you to visit with me, the Director of Nursing, or the Administrator. The letter failed to provide contact information for the grievance official, information on the mechanism for submitting a grievance in writing or anonymously, or the right to receive the grievance decision in writing when requested. A review of the facility's policy titled, Complaint Process, last review date 12/2020, failed to show the following required criteria: - notify residents of the right to file a grievance anonymously, - contact information for the grievance official, - the expected time frame for completing the review of the grievance, - the right to obtain a written decision regarding the resolution of the grievance, and - identification of a grievance official responsible for overseeing the grievance process.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to investigate whether any other residents were affected by improper treatment from the accused staff member. A review of the investigation of a facility reported incident which occurred on 11/23/19, showed an allegation of resident mistreatment by a staff member. The document showed staff member G was giving resident #264 a shower and sprayed water in the resident's face in order to remove the gunk in her eyes. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigative document showed [staff member H] stated, [staff member G] had taken the hose and sprayed in [resident #264] face three times. [Staff member G] would hold the water on [resident #264] face and it was like [staff member G] didn't care. [Resident #264] would try to fight it and would move. [Staff member G] put soap in [resident #264] eyes and sprayed her face. The investigation documents failed to identify if the mistreatment was or was not abuse and if any other residents were affected. During an interview on 8/31/21 at 9:20 a.m., staff member A stated no resident interviews were completed after the incident involving resident #264 and staff member G; no attempt was made to determine if any other residents had potentially been abused. A review of the facility's policy titled, Investigation & Reporting of Suspected Patient Abuse, last review date 12/2020, showed the investigation included interviewing the resident, witnesses, and others potentially involved. The investigation documents failed to show who was interviewed for potential involvement, such as other staff or residents who may have witnessed, or been subject to the mistreatment by staff member G.

Based on observation, interview, and record review, the facility failed to notify the resident and the resident's representative of the reason for the transfer in writing, and failed to provide a copy of the transfer notice to the State Long-term Care Ombudsman, for 2 (#s 33 and 62) of 2 sampled residents. Findings include: 1. During an interview on 8/29/21 at 9:05 a.m., resident #33 stated he had been hospitalized a couple times in 2021. He could not remember exactly when these admissions were but stated they were for his gall bladder and his heart. A review of resident #33's Resident to ER/Acute Care Transfer Summary, dated 3/13/21, showed he was transferred to the emergency department with chest pain and an irregular heartbeat. The section for family notification was blank. A review of resident #33's Notice of Transfer or Discharge, not dated, was completely blank. A review of resident #33's Resident to ER/Acute Care Transfer Summary, dated 4/1/21, showed he was transferred to the emergency department because he was found unresponsive. The family notification section showed family had been notified. A review of resident #33's Notice of Transfer or Discharge, not dated, was completely blank. 2. A review of resident #62's Resident to ER/Acute Care Transfer Summary, dated 7/16/21, showed she was transferred to the emergency department because of stroke symptoms. The section for family notification was blank. Resident #62 was not at the facility and could not be interviewed. A review of resident #62's Notice of Transfer or Discharge, not dated, was completely blank. During an interview on 8/30/21 at 8:43 a.m., staff member A stated the facility did not fill out the transfer notice when a resident went to the emergency department. Staff member A stated the family was notified when a resident was transferred to the emergency department, and was instructed to meet their family member there. Staff member A stated they have not been notifying their local Ombudsman when a resident was transferred. A review of the facility's policy, Bed-Hold Notice/Discharge/Readmit/Transfer, last review date 3/2021, failed to show a written notice of the reason for transfer was required for all facility-initiated transfers. The only resident or family notification mentioned in the policy was related to a telephone notification to family of the transfer.

Based on interview and record review, the facility failed to provide written bed-hold information to the resident and the resident's representative when residents were transferred to the emergency department or admitted to the hospital for 2 (#s 33 and 62) of 2 sampled residents. Findings include: 1. During an interview on 8/29/21 at 9:05 a.m., resident #33 stated he had been hospitalized a couple times in 2021. He could not remember exactly when these admissions were but stated they were for his gall bladder and his heart. A review of resident #33's Resident to ER/Acute Care Transfer Summary, dated 3/13/21, showed he was transferred to the emergency department with chest pain and an irregular heartbeat. The section for family notification was blank. A review of a Bed-Hold Notice stapled to resident #33's 3/13/21 transfer summary was blank. No resident name, no daily room rate, no date, and no resident or family signatures were found on the form. A review of resident #33's Resident to ER/Acute Care Transfer Summary, dated 4/1/21, showed he was transferred to the emergency department because he was found unresponsive. The family notification section showed family had been notified. A review of a Bed-Hold Notice stapled to resident #33's 4/1/21 transfer summary was blank. No resident name, no daily room rate, no date, and no resident or family signatures were found on the form. 2. A review of resident #62's Resident to ER/Acute Care Transfer Summary, dated 7/16/21, showed she was transferred to the emergency department because of stroke symptoms. The section for family notification was blank. Resident #62 was not at the facility and could not be interviewed. A review of a Bed-Hold Notice stapled to resident #62's 7/16/21 transfer summary was blank. No resident name, no daily room rate, no date, and no resident or family signatures were found on the form. During an interview on 8/30/21 at 8:43 a.m., staff member A stated the facility sent the blank Bed-Hold Notice form with the resident's transfer documents. Staff member A stated filling out the Bed-Hold was not part of their process when a resident was transferred to the emergency department or admitted to the hospital. A review of the facility's policy, Bed-Hold Notice/Discharge/Readmit/Transfer, last review date 3/2021, showed, Upon admission or transfer from [facility name] to another facility, the resident/family/responsible party shall be informed of the [facility name] Bed-Hold Policy. and . Bed-Hold Notice shall be filled out and responsible party signatures shall be obtained.

Based on observation, interview, and record review, the facility failed to ensure an as needed (PRN) [CONDITION(S)] medication was reviewed after 14 days, and the facility failed to ensure the medication was discontinued unless a rationale for continuing the medication was documented by the physician, for 1 (#10) of 5 sampled residents. Findings include: During an observation and attempted interview on 8/28/21 at 4:23 p.m., resident #10 nodded to the surveyor and attempted to answer questions verbally. Resident #10's speech was slurred and very difficult to understand. Resident #10 nodded up and down, and shook his head back and forth in response to yes or no questions. Resident #10 did not express agitation or aggressive behaviors during the observation and interview. During an interview on 8/31/21 at 10:10 a.m., staff member E stated when pharmacy reviews were done the use of as needed [CONDITION(S)] medications beyond 14 days was not one of the things reviewed. After reviewing resident #10's medical record, staff member E stated the lorazepam was continued from the resident's hospital stay, which was why it was not identified. Staff member E stated she was not aware the facility policy did not include any language related to the 14 day limit for as needed [CONDITION(S)] medications used. A review of resident #10's physician order, dated 5/6/21, showed a current order for lorazepam 1 mg every four hours as needed for agitation. The 14 day limit occurred on 5/20/21. A review of resident #10's MAR, dated May 2021 through August 2021, showed lorazepam 1 mg had been given a total of 11 times, with the last dose documented as given on 8/26/21. A review of resident #10's physician progress note, dated 6/9/21, failed to mention the use of as needed lorazepam for agitation. The note showed scheduled [MEDICATION(S)] was being given for agitation. A review of resident #10's monthly pharmacy medication regimen reviews, dated June 2021 through August 2021, failed to identify as needed lorazepam as a medication irregularity requiring physician review. A review of resident #10's Determination of Clinical Contraindication, dated 7/12/21, showed the resident had an enduring psychiatric condition which was being managed on a stable medical regime. A review of all physician documentation in the medical record, between 5/20/21 and 7/12/21, failed to show any rationale for continuing the as needed lorazepam until 7/12/21. A review of the facility's policy, Psychopharmacological Medications, last review date 12/2020, failed to show any language indicating the need for review of as needed [CONDITION(S)] medications after 14 days.

Based on interview and record review, the facility failed to safeguard a resident's personal property for 1 (#33) of 2 sampled resident. The resident's property was taken by staff for infection control purposes and not returned. The deficient practice resulted in mental stress for the resident. Findings include: During an interview on 8/29/21 at 9:03 a.m., resident #33 stated during the time he had COVID-19, he was moved to a room on the COVID-19 unit. Resident #33 stated when he had recovered and was moved back to his regular room, someone had cleaned and had thrown some of his property away. Resident #33 stated, I lost everything. During an interview on 08/30/21 at 11:33 a.m., staff member A stated during the COVID-19 outbreak in October and November of 2020, when a resident who had recovered from COVID-19 and was returned to their regular room, any personal belongings used on the COVID-19 unit were placed in a clear plastic bag which was tied closed and left on the unit for 24 hours. After 24 hours in the bag, the items were returned to the resident. Staff member A stated the facility eventually realized the clear plastic bags were being mistaken for garbage, and were being thrown away. Staff member A did not know if that was what had happened to resident #33's property. Staff member A stated the nurse who documented the missing items was a travel nurse, and may not have known she was supposed to notify the social worker when personal property went missing. Staff member A stated due to the competing priority of COVID-19, the facility did not make any attempt to determine which residents may have lost property. During an interview on 8/30/21 at 2:40 p.m., staff member D stated she was off work for medical reasons for approximately two weeks during October of 2020. During the time she was out, staff member D stated nursing administration was covering her duties, including the issue of lost or missing resident property. Staff member D stated all resident complaints, including lost items, were supposed to go through her, or her designee. Staff member D stated she was not aware resident #33 had lost items when transferring between the COVID-19 unit and his regular room. During a medication administration observation on 8/31/21 at 7:44 a.m., resident #33 stated someone had thrown away his property when he was in the COVID-19 unit, and wanted someone to do something about it. A review of resident #33's Nursing Progress note, dated 10/29/20, showed the nurse was made aware the resident was missing his wallet and hearing aid. The note showed a search of the unit failed to find the items, and, FYI all staff member to keep and [sic] eye out for resident personal items. Review of the facility policy titled, Missing Items/Complaint Log, dated 12/2019, showed, Any and all resident complaints shall be reported to the Social Services director/designee. The purpose of the policy was, To provide a procedure to investigate resident complaints . and to, maintain a log of investigations into resident grievances regarding missing or lost items. Review of the facility's missing item log, dated from 5/4/20 to the present, showed no listing for resident #33 during the months of October and November of 2020.

Based on interview and record review, the facility failed to have a process in place to address residents' concerns regarding lost clothing for 2 (#s 9 and 57) of 22 sampled residents. Findings include: During an interview on 11/12/19 at 3:26 p.m., resident #9 said he had a lot of clothing go missing since he was admitted to the facility. The resident said he had told the bosses about his missing clothes. He said no one had talked to him or told him what the facility would do if his clothing was not found. Resident #9 said he wished the facility would replace his missing clothes. During an interview on 11/13/19 at 9:32 a.m., resident #57 said she was missing two skorts and one tank top. She said they had been missing for at least four weeks. The resident said none of the staff had updated her on the search for her missing clothes. She said her clothing was not marked with her name. The resident said some staff told her the laundry would mark her clothes before they were washed and other staff told her the clothing would be marked after they were washed. Resident #57 said she told a CNA about her missing clothes. The resident said no staff member had given her an update on her missing clothing. During an interview on 11/14/19 at 8:01 a.m., staff member A and staff member B said the facility did not use grievance forms to report missing resident clothing. Staff member A said the facility did not have a written procedure for reporting lost resident clothing. Staff member A said staff know to send staff member B an email when a resident reports lost clothing. Staff member A said staff member B would then contact laundry about the missing clothes. Staff member A said, Most times reports of lost clothing, staff get on it right away and the clothing is found within an hour. Staff member B said she was not aware resident #9 was missing any clothing. Staff member B said she knew resident #57 had missing clothing and it had not been found yet. Staff member A said the facility did not have a written procedure for reporting lost clothing or a procedure for follow-up on missing clothing. A review of the facility's Grievance policy failed to show the facility addressed residents' lost clothing concerns through grievance reporting.

Based on observation, interview, and record review, facility staff failed to ensure the medication error rate was less than 5%, which affected 2 (#s 9 and 23) of 23 sampled and supplemental residents. The facility medication error rate was 5.7%. Findings include: 1. During an observation and interview on 11/13/19 at 8:46 a.m., staff member C prepared medications for resident #9. Staff member C stated resident #9 was independent and could self-administer a Metered Dose Inhaler (MDI) without assistance. At 8:48 a.m., staff member C entered resident #9's room and handed the resident a MDI. Resident #9 inhaled two puffs from the [MEDICATION NAME] MDI simultaneously. Staff member C did not instruct resident #9 to rinse his mouth with water and spit after the [MEDICATION NAME]. During an interview on 11/13/19 at 4:00 p.m., staff member C stated she should have reminded resident #9 to rinse and spit after the use of [MEDICATION NAME] MDI. Staff member C stated resident #9 was at risk for developing oral thrush if he did not rinse his mouth with water and spit after using the MDI. Review of resident #9's (MONTH) 2019 Medication Administration Record [REDACTED]. 2. During an observation and interview on 11/13/19 at 3:49 p.m., staff member C prepared medications for resident #23. Staff member C stated resident #23 was a new resident, was independent, and could self-administer a MDI without assistance. At 3:51 p.m., staff member C entered resident 23's room and handed the resident her MDI; [MEDICATION NAME]. Resident #23 took two puffs of the inhaler followed by several oral medications. During an interview on 11/13/19 at 4:02 p.m., staff member C stated she did not realize resident #23 had inhaled two puffs of [MEDICATION NAME] instead on one puff. Staff member C stated resident #23 possibly did not get a good first puff and that is why (resident #23) took a second puff. Staff member C stated she should have provided education to the resident regarding MDI orders; 1 puff every 6 hours. Review of resident #23's (MONTH) 2019 MAR, showed orders for [MEDICATION NAME] inhaler 1 puff every 6 hours.

Based on observation, record review, and interview, the facility failed to maintain the highest level of well being for 1 (#12) of 19 sampled residents. Findings include: 1. The resident was admitted to the facility with end stage [MEDICAL CONDITION]. During a group meeting on 5/25/16 at 9:30 a.m., resident #12 was observed to verbalize [MEDICAL CONDITION] to the point of saying, If I had a gun on the table in front of me, I wouldn't be able to pull the trigger but if someone would put some pills in front of me to take so I could die, I would take them. The resident was observed to be tearful and slightly agitated. Review of nursing notes identified the resident as depressed or having the appearance of feeling down on 3/11/16, 3/7/16, and 3/6/16. Nursing notes documented resident voicing ready to die or better off dead to nursing staff on 5/23/16, 5/17/16, and 5/7/16. Nursing notes showed the social worker was contacted on 5/23/16, 5/17/16 and 3/7/16. Review of the resident's record showed an order, dated 3/7/16, indicating resident #12 was to see a psychologist due to the resident stating he felt depressed. The record showed resident #12 was seen by the psychologist on 3/15/16. The psychologist noted, We discussed his depression and the patient stated that he believes in 'assisted suicide.' He stated that if someone were to put several guns in front of him, he would not shoot himself, however, if someone were to give him a pill to end his life, he would take it. At the end of this progress note it stated she would see resident #12 for a follow-up appointment on 3/28/16. The record contained no documentation to show the psychologist saw the resident on that date or a reason why she did not. There was no evidence in the resident's record of the psychologist following up with him during the month of April 2016. The psychologist saw resident #12 on 5/9/16 for a follow-up visit. The psychologist noted in her progress note, The patient appeared depressed and described his mood as such. And, He was tearful at time throughout the session while discussing happier time in his past. The psychologist stated she would see him again in a couple of weeks. Another progress note from the psychologist showed she attempted to visit with him on 5/23/16 but resident #12 was not in his room. Review of the primary physician's progress notes, from 5/10/16 and 4/9/16, did not show any mention of resident #12's depression, [MEDICAL CONDITION], or the fact resident #12 had meetings with the psychologist regarding his depression. Review of resident #12's Medication Administration Record [REDACTED]. Review of a progress note by staff member D dated 5/25/16 at 3:11 p.m., showed staff member D had visited with resident #12 and his daughter about the resident taking an antidepressant. Resident #12 said he would be willing to give it a try. During an interview on 5/25/16 at 1:00 p.m., staff member D thought resident #12 was receiving an antidepressant. Staff member D said nursing staff had not communicated to her resident #12's thoughts of [MEDICAL CONDITION]. Staff member D said she was not aware resident #12 had not seen the psychologist on 5/23/16. During an interview on 5/25/16 at 1:00 p.m., staff member C said resident #12 was not in his room when the psychologist came to visit him. Staff member C said doctors tend to pop in and out of the facility and do not make nursing staff aware they are in the facility.

Based on observation, staff interview and policy and record review, the facility failed to: investigate causes of falls; determine risk factors from falls; develop individual interventions based on the residents fall history; revise care plans and implement care plans to ensure residents were free from injury of falls for 6 (#s 8, 10, 11, 22, 23, 24) out of 24 sampled and supplemental residents. Specific failures were: 1. Resident #8 had eight falls. Four of the falls occurred prior to the facility implementing new interventions to prevent future falls or injury from falls. The resident hit his head on three of the falls, two of these causing head abrasions. The facility failed to utilize the resident's fall history to develop an effective plan of care to prevent falls with injury. The facility failed to follow the resident's plan of care for fall prevention. 2. Resident #10 had 13 falls within the last year. For the first eight falls, six caused injury. The facility failed to implement specific interventions utilizing the resident's history of falls and causal factors. After each fall, the facility failed to revise the care plan to prevent future falls or falls with injury. For the most recent fall, staff failed to follow the resident's individualized care plan. The resident was unsupervised, fell , and sustained a fracture. 3. Resident #11 had 27 falls within the last year (between 5/20/13 to 6/3/14.) Fifteen of these falls were with injury. He had one hip fracture, four injuries to the head (one being a contusion to the back of his head), four abrasions and 11 skin tears. The facility failed to utilize the resident's fall history to develop an effective plan of care to prevent falls. 4. Resident #22 had 12 falls since admission on 11/12/13. Eight of the falls were with injury. Record review indicated she was seen in theER on three occasions following falls. She sustained multiple skin tears, abrasions, lacerations to her forehead and nose, and hip pain. She was seen by an APRN in the facility for one fall, with a laceration to the back of her head. She sustained multiple skin tears and abrasions during falls that did not require an ER visit. The facility failed to utilize the resident's fall history to develop an effective plan of care to prevent falls. 5. Resident #23 had four falls within the last year. One of the falls resulted in a fracture of her hip. The facility failed to update the resident's plan of care for fall prevention related to mobility, ADL care, and document attempts to prevent future falls. The facility routinely disposed of the Pocket Care Plan, which in turn did not allow the facility to effectively show they attempted to prevent accidents with injury. 6. Resident #24 was not toileted immediately after meals resulting in multiple falls to include one fall that resulted in a major injury that required surgical intervention. IMMEDIATE JEOPARDY Six residents (# 8, 10, 11, 22, 23, 24) did not receive services necessary to avoid physical harm related to their fall risk. Staff failed to include interventions in the current care plan to prevent future falls. Staff did not actively follow and carry out interventions on the active care plan to prevent future falls. Six residents experienced falls with major injuries. On 6/6/14 at 2:30 p.m., the facility administrator and DON were notified by the survey team that an immediate jeopardy situation existed in the area of Quality of Care for 6 (#s 8, 10, 11, 22, 23, 24) sampled and supplemental residents that had experienced falls with major injury. The areas of deficiency included F224-neglect and F323-accidents and hazards. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to abate the immediate jeopardy on 6/6/14 at 12:50 a.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: Policy changes/additions: -the care plan included the Care Center Care Plan, the RAI (Kardex), and the Pocket Care Plan; -assessment will be done within 12 hours of admit, including steps required by admit; -plan of care will be reviewed after each fall to include assessment, review of the fall (evaluation of causal factors), develop a plan, communication of plan to staff, and documenting interventions; -falls will be re-evaluated by falls team and at total care meetings and will be adjusted with new interventions and communicated with staff per policy; -staff shall initiate appropriate interventions to address identified risk factors as per policy; -care plans must be revised after every fall with the interventions identified; and, -all Pocket Care Plans, Care Center Care Plans and RAI (Kardex) plans are considered part of the resident's record and shall be treated accordingly. They will be dated and retained and scanned into the facility Meditech electronic record. Communication changes/additions: -information will be shared at shift report; -specific individualized interventions will be added to the resident plan of care; -the administration will educate all employees of the necessity of following the Falls Policy; -the care plan will be revised and communicated to all staff for all changes made immediately and at change of shift along with the reviews by the Falls team; -the RN or LPN will complete the task of communicating changes to all staff at the end of each shift; -staff will be educated on the revisions to the care plan at staff shift report; and, -when the Pocket Care Plan, Care Center Care Plan, and RAI (Kardex) are revised, they will be scanned into Meditech by the appropriate staff per organizational access. Monitoring changes/additions: -RN/LPN will be responsible to monitor that each of the steps in the Falls policy are followed and report any variances to the DON. The DON will be responsible for overall monitoring of these corrections; -RN/LPN will be responsible to monitor that each of the steps in the Falls policy are followed and report any variances to the DON. Quality Action reports are reviewed with appropriate recommendations on a daily basis at administrative morning report. The DON will be responsible for the overall monitoring of the corrections; and, -Ward clerks will route the Pocket Care Plans, Care Center Care Plans, and RAI (Kardex)for scanning to the appropriate staff per organizational access. The DON will be responsible for the overall monitoring of these corrections. Specific corrective action for each of the 6 residents (#8, 10, 11, 22, 23, and 24) listed above were addressed as follows: 1. Resident #8 had changes to his care plan to include: -leaving his room door partially open for staff to visually see when passing; -ensure his position in bed is in the middle, with body pillow; -reminder to offer the use of the recliner after meals; -keep glasses clean and within reach at all times; -check often for incontinence; -observe for increased need for ADL assistance; -overhead light attached to pillow; -mattress to floor in case he falls from bed; -bed in low position; and, -overbed table near resident when in bed/chair. 2. Resident #10 had changes to her care plan to include: -turning and positioning schedule, and to reassess every two hours to determine if she needs to be repositioned; -if restless, investigate for potential pain issues; -encourage sitting positioning in television room in recliner, with shows she prefers; -if restless and is uneasily altered, enlist a one to one for an activity; -assistance of two people for transfers; -weight bearing precautions and new transfer status with slide board and gait belt; -wheelchair for transporting; -low bed, always while in bed; -bedside commode; -walker placement out of line of sight; -assistance with toileting, staff to stay within line of sight at all times; -poor awareness of safety needs; -additional detailed behaviors were added (not all inclusive); and, -frequent room checks for safety, keeping the door open for visual check of the resident. 3. Resident #11 had changes to his care plan to include: -check every 15 minutes to maintain safety of resident; -nurse will monitor this every hour and document showing this observation has been completed and properly documented; -assist of one with gait belt and walker to and from meals and with ADLs; and, -assess for weakness to ascertain as to whether wheel chair should be used. 4. Resident #22 had changes to her care plan to include: -Sara lift for transfers; -3-day bladder diary to evaluate effective toileting plan -toileting schedule to be established following the 3 day bladder diary; -Physical Therapy services; Balance Test performed by Physical Therapist. Recommends a Neurologist consult for Ataxia, order received by PCP on 6/5/14; and, -discuss with PT on 6/7 the appropriateness of size of wheelchair and use of wheelchair legs. 5. Resident #23 had changes to her care plan to include: -when in wheelchair, keep within sight of staff for safety; -place call light over bathroom door handle so it's within reach, and remind her of location; -Sara lift; -bladder diary to determine bladder habits and needs; -physical therapy consult for balance testing and size of wheelchair legs; and, -neurologist consult for ataxia. 6. Resident #24 had changes to her care plan to include: -for each meal she will be the last resident toileted on pre-meal rounds; -the timing of the meal tray delivery will be arranged to promote optimal duration of staff supervision; -the resident will be toileted upon completion of her meal and returned to the dining room to be offered additional fluids and provide resident socialization and staff oversight; -toileting will be carried out by all staff; -all staff will toilet resident #24 at the start of each shift and then every two hours; and, -all toileting will be carried out by all staff members. The correction plan was accepted and the immediate jeopardy was abated on 6/6/14 at 12:50 a.m. The deficient practice remained at the scope and severity of an H once the immediate jeopardy was abated. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, with an ARD of 3/4/14, coded resident #8 as needing extensive assist of one person for bed mobility, transfers, dressing, eating, toileting and personal hygiene. From 6/5/13 to 3/23/14, resident #8 had seven falls, five with injury. He hit his head on three occasions, two causing abrasions. The falls occurred on: 6/5/13, 7/2/13, 9/13/13, 10/3/13, 10/31/13, 1/10/14, 3/6/14, and 3/23/14. Causes of the falls included: five falls from self transferring, two falls from rolling out of bed, one fall from reaching too far. After the residents 6th fall, dated 1/10/14, the nurse implemented two interventions, a low bed and use of the call light. The falls on 3/6/14 and 3/23/14, occurred when the resident rolled out of bed onto the floor, hitting his head. Both falls caused an abrasion to his head. A fall mat was added to the interventions for the 7th fall on 3/6/14 per the Fall Assessment form. For the fall on 3/23/14, the physician notification was not evident in the medical record. A new intervention for fall mat was entered on the Assessment form. There's no evidence that the new intervention was carried forward when recommended on 3/6/14 to the care plan. The intervention on 6/5/13, showed the resident was not to be left unattended in his room in his wheelchair after meals. On 6/5/14, 7/2/14, 9/13/13, 10/3/13 the resident fell while unattended in his room in his wheel chair. The Fall Assessment form on 3/23/14, did not reflect that the physician was notified of the fall. The resident hit his head which resulted in an abrasion. The care plan for resident #8 was comprised of three parts: -Pocket Care Plan-(last revision not dated) The fall category for resident #8 had one intervention, "Geri chair for all meals." -Care Center Care Plan-last fall revision 3/23/14 This included the dates of the resident's falls, with the intervention to assess for injury with falls. -RAI (Kardex)-Care Area 11 Falls -last revision 3/5/14 The care problem was documented as cognitive loss and dementia. The causes included leaning, which caused him to fall. The resident's falls (interventions) were documented as, "Anticipate (resident's) needs as much as possible; Assist with all mobility needs." On 6/6/14 at 10:55 a.m., resident #8 was observed unattended in his room sitting in his Geri chair. On 6/6/14 at 11:35 a.m., resident #8 was sitting in his room in a recliner. Staff member K, a CNA, who was assigned to resident #8 for the day, was interviewed on 6/6/14 at 7:35 a.m. She stated resident #8 used a geri chair for meals only. He was unable to bear weight, and had a fall pad for fall prevention when in bed. Staff member K showed her Pocket Care Plan, which she used daily. Resident #8 was observed, unattended in his room sitting in his geri chair. On 6/6/14 after breakfast resident #8 was observed throughout the morning, unattended in his room, sitting in his Geri chair. At 11:35 a.m., the CNA stated she had not returned the resident to his room after the morning meal, and was unsure who did. She stated she had checked on the resident after breakfast, but had to go to lunch. The resident Pocket Care Plan, which the CNA had produced earlier included documentation about not leaving the resident in his room in his Geri chair unattended. Staff member L, RN, who was assigned to his care was interviewed on 6/6/14 at 11:05 a.m. She stated resident #8 can no longer push himself to meals, so staff assist him to and from the dining room. She indicated the CNA was at lunch. Staff member L stated she did not know why resident #8 was in a Geri chair throughout the morning. 2. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #10 had 13 falls documented on the Fall Assessment forms, between 12/3/13 and 5/28/14. Past falls included: 12/3/13-Resident reported a fall in bathroom/no injury; 12/28/13-Found on floor/skin tear right elbow, pain in right wrist; 2/23/14-Bent over and fell /skin tear to right forearm; 3/9/14-Self reported fall/bruising left shoulder; 4/8/14-Self reported fall off bed/hit head; 4/15/14-Getting out of bed and fell to knees/no injury; 4/16/14-Self reported fall off bed/hit head and had a headache, and her "bottom" hurt; 4/24/14-Self transferred with pants down and fell /pain to buttocks; 4/26/14-Attempted to sit, tipped chair and fell /no injury; 5/15/14-Walking and fell /skin tear to left elbow; 5/21/14-Walking and fell /hip pain; 5/22/14-Constantly moving from sitting to standing position and fell /pain from hitting head; 5/28/14-A staff member toileted the resident, then turned away, leaving the resident unattended. The resident got up from the toilet and walked with her pants down and fell . She suffered an abrasion to her low back and hip pain. The resident was sent to the emergency room and diagnosed with [REDACTED]. The resident's current care plan included an intervention not to leave the resident unattended on the toilet. Interventions located on the Fall assessment form included the following past and future interventions: 12/3/13-Blank/None; 12/28/13-Blank/N (none); 2/23/14-Blank/N (none); 3/9/14-Blank/N (none); 4/7/14- Observation/N (none); 4/15/14-Blank/N (none); 4/16/14-Observation/N (none); 4/24/14-Call light, toilet, encourage walker/low bed, monitor, stay with while toileting; 4/26/14-Call light, toilet, encourage walker/N (none); 5/15/14-Call light, low bed/Blank; 5/21/14-Call light, low bed/N (none); 5/22/14-Blank/low bed, monitor, stay with resident; and, 5/28/14-Low bed, stay with while on toilet, call light in reach/N (none). Based on the fall documentation, the resident had four falls prior to the facility implementing the intervention of "Observation." After the 8th fall, the resident had three new interventions implemented. For the 13 falls, the implemented interventions had little changes made, and the resident had repeat falls after the implementation of the interventions. A Fax Request Order form dated 4/28/14 included a physician's orders [REDACTED]. On 5/21/14, a Fax Request Order form was sent to the physician, notifying him of another resident fall. The documented response on the fax communication, from the physician, included, "Pt (sic) to eval and treat for frequent falls unless already ordered. (Physician name) to see (sic) Dx: worsening anxiety." A physical therapy evaluation was completed on 4/29/14. This was for decreased functional mobility. The therapist documented the resident's history as: she had stopped using her 4 wheel walker, which she had been independently using up to two months prior; had increased falls; shuffled her feet when walking; and, unable to respond as well when communicating. On 5/12/14, the treatment plan for the physical therapy was discontinued on 5/9/14 due to the resident reaching her prior level of functioning. The therapist documented, "PT (sic) ignores verbal cues for safety...continuing to make her high fall risk. With her dementia she is unable to follow an exercise program. Staff instructed to cont (sic) amb (sic) program..." On 1/9/14, the nursing progress notes indicated the resident was choking, while unattended in her room. A staff member performed the Heimlich maneuver and dislodged the item. The facility care plan included three components, which were, the Pocket Care Plan, the Care Center Care Plan, and the RAI (Kardex). -Pocket Care Plan (last revision undocumented) included the following: Under Safety Devices, Falls/Elopement, documentation included, "Multiple falls, bed in lowest position, stay with (resident) while on toilet." The Pocket Care Plan used daily by the CNAs did not address a choking risk. -RAI (Kardex) -falls revision 5/28/14 On the resident's RAI Assessment, category Care Area #11- Falls, the documentation included, "See psychotropic drug use CAA... Date of CAA documentation: 4/11/14." Review of Care Area 17, Psychotropic drug use, included the documentation, "Ms. (resident) has two reported falls in the past quarter. One in February with a small skin tear and one in March where she had bruising of unknown origin and she told staff she had fallen. No falls witnessed and no other injuries identified." A goal for the resident's falls included, "(Resident) will remain from from injury related to falls during the next quarter." The intervention for this plan included, "Keep room free from clutter and trip hazards." The ADL Functional/Rehabilitation Potential on the care plan showed the resident was: independent with transfers; independent with ambulation to and from the bathroom and to and from the dining room; continued to use her four wheel walker for stability; independent with locomotion; and independent with her dressing and toileting needs. Care Area 15: Dental Care, included documentation of the risk factor: Edentulous-potential for choking on foods. The care plan did not include interventions related to choking risk. The nursing progress note, dated 1/9/14, did not include interventions to prevent future choking episodes. -Care Center Care Plan with a fall revision dated 4/11/14, included in the ADL category: "Falls; Resident placing self on floor stating that the floor is cooler and prefers that at times. This is a planned event; Document with each fall." The dates of the resident's previous falls were included on the care plan. During the time span of 12/2/13 to 5/22/14, resident #10 had 20 physician ordered medication changes to her antidepressant, hypnotic, antianxiety, anticonvulsant, Parkinson and antipsychotic medication. Staff member J, CNA, was interviewed on 6/4/14 at 8:30 a.m. Staff member J was assisting resident #10 in the bathroom when the fall on 5/28/14 occurred. She stated, "I turned for just a second, went to grab the wipes...she got up and went right past me...fell there (pointed outside the bathroom by the resident's bed and wheelchair), her pants were down (pointing to her ankles), and she tripped. They sent her to the ER." The CNA stated the resident, "plops down", when sitting. She reported the resident has a low bed, gets agitated, has to urinate often, uses her light to call for help, and needs frequent reminders due to poor cognition. Staff member J was utilizing a copy of the resident's Pocket Care Plan which she carried in her uniform pocket. The Pocket Care Plan included the documentation not to leave the resident unattended on the toilet. A review of the Fall Committee meeting minutes, dated 8/13-4/14, lacked resident specific information for the prevention of falls. The committee began reviewing the Fall process on 8/23/13, in an attempt to decrease the number of falls. The May 2014 meeting minutes did include resident specific information, which was nine months after the committee began reviewing the Fall process. Resident #10 was not included in the May meeting minutes. Minutes from the Rapid Cycle Fall Team were reviewed dating back to August 23, 2013. The Falls Protocol policy, with an effective date of 03/12, directed staff to assess a fall when it occurred and attempt to: identify the cause of the fall, evaluate causal factors, determine interventions, and document interventions for future prevention. 3. Resident #11 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident resided on the locked special care unit. The resident had resided there since 8/13 when he had been moved with family approval due to aggression towards his wife and exit seeking behavior. He had resided with her on another unit of the facility. Review of the Minimum Data Set with the ARD of 4/2/14 indicated the resident was an extensive assist of one person with his ADLs. During an interview on 6/2/14 at 11:15 a.m., staff member G, an RN, stated, "(resident #11) was moved from west unit to the special care unit 6 months ago. He had some fighting with his wife. With his ADL's he is an assist of one or two. He is resistive at times with this assistance. He foot propels his wheelchair. Sometimes uses a walker. He feeds himself." The resident's room was observed to be clutter free on 6/2, 6/3, 6/4 and 5/14. During an interview on 6/3/14 at 9:12 a.m., staff member G, a registered nurse, indicated resident #11 had fallen during the night and knew the resident had not hit his head by the way he was positioned on the floor. She indicated the resident had good Neuros and good vitals. The fall had not been witnessed. a. Documented injuries from falls. The falls assessments and faxed request for orders were reviewed on 6/4/14. These documents indicated the resident had 27 falls documented for the time range of 5/20/13 to 6/4/14. The following were the falls with injury during this period: -5/20/13 was an unwitnessed fall in his bedroom. The resident sustained [REDACTED]." The resident was sent to ED due to his complaints of hip pain. The resident returned from the ED with a fractured hip. -7/12/13 was an unwitnessed fall. The resident received a skin tear to his right shoulder. -7/13/13 the resident fell in the hallway. The resident sustained [REDACTED]. -7/21/13 was an unwitnessed fall. The resident received a skin tear to right inner forearm. -9/8/13 fell while standing over the toilet. The resident sustained [REDACTED]. -10/17/13 was an unwitnessed fall. The resident sustained [REDACTED]. There was a dark purple bruise around the skin tear. -11/10/13 resident fell backwards coming from nourishment room. The resident hit his head. The resident received a skin tear on his cheek and a bruise on the anterior aspect of his right arm. -12/24/13 the resident fell trying to get his door open. This resulted in a skin tear to his left elbow. -12/25/13 received a skin tear from this fall. -2/17/14 the resident was sitting on his chair and fell backwards. This resulted in a contusion to the back of his head. -3/6/14 was an unwitnessed fall in his bedroom. This resulted in a skin tear to his right forearm with a dark bruise around it. -3/11/14 the resident lost his balance after turning his walker coming from his room. This resulted in 2 skin tears to his knuckles with a dark bruise on 3 of the knuckles. -3/26/14 (at 3:25 p.m.) was an unwitnessed fall in his room. The resident had a reddened cheek. -3/26/14 (at 8:00 a.m.) fell out of bed. This resulted in a small abrasion to his left great toe. -4/11/14 rolled out of bed. This resulted in a large skin tear to his upper arm. -4/17/14 was found beside his bed. This resulted in an abrasion to his back and left shoulder. c. Review of the falls assessments for the period of 6/4/14 to 5/20/13 included suggested changes and interventions that were indicated to be in the CC Care Plan. These suggested changes and interventions were noted on: -7/13/13 "Interventions that were in place at the time of the fall: other Were interventions effective? yes New interventions implemented as a result of this fall? yes close observation." -9/8/13 "Interventions currently used to prevent falls: Monitoring. Res. up independently. Changes to the care plan as a result of this fall: Stay with res. when using the toilet." -1/3/14 "Interventions in place at the time of fall: Monitor closely Observation" -2/17/14 "Interventions in place at time of fall: Monitor closely Observation" Interventions currently used to prevent falls: Continue to monitor GCS for fall 10/3 and again 10/8. Encourage resident to sit with other residents and staff supervision as much as possible." -3/3/14 "Interventions in place at time of fall: Monitor closely Observation" -3/6/14 "Interventions in place at the time of fall: Monitor closely Observation" -3/11/14 "Interventions in place at time of fall: Monitor closely observation" -3/26/14 "Interventions in place at time of fall: Observe for possible falls especially when getting up" -6/3/14 "Interventions in place at time of fall Low bed frequent checks." Review of the Care Center Care Plan (CC Care Plan) on 6/4/14 indicated the resident had a goal to not fall over the next quarter. The plan included that staff would assist with activities of daily living as needed and to offer a clutter free environment. The above noted interventions had not been included in the CC Care Plan to address falls. During an interview on 6/6/14 at 5:40 p.m., staff member CC, an RN stated, "I thought the revisions to the plan were in the kardex but they are not. (resident #11)'s pocket care plan needs to be updated. He no longer lives on west. He's at a place now he needs an assist of one not frequent checks. He has declined out of walker. He was doing a walker now its a wheelchair." At this time staff member CC was observed to mark out the walker on the pocket care plan and write in wheelchair. She also marked out When asked about how long ago was this decline staff member CC states, "I hate to put a number on it. He's been brought to the dining room the last 2 weeks." Review of the policy to reduce falls with the revision date of 3/12 included the procedure to have individualized interventions added to the resident's care plan to help decrease frequency of falls and minimize injury with falls. During an interview on 6/6/14 at 6:52 p.m., staff member DD, a CNA when asked if he felt there were a lot of falls at the facility and why, stated, "Too many. Not specifically trained to deal with falls. Our problem is we don't know where fall risk are at. We have a tendency to get stuck in the dining room and can't see what's going on elsewhere on the unit." 4. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. A review of the MDS with an ARD of 11/13/13 showed evidence resident #22 had a history of [REDACTED]. A review of the MDS with an ARD of 2/6/4 showed evidence resident #22 had two or more non-injury falls, and two or more falls with injury in the first quarter (J1800 A and B). A review of the MDS with an ARD of 5/1/14 showed evidence resident #22 had two or more non-injury falls, and two or more falls with injury in the second quarter (J1800 A and B). The following forms, labeled FALLS ASSESSMENT, Falls Assessment, and List Patient Notes, were reviewed and contained the following information: Note: The falls assessments and list patient notes were written in all capital letters on the original documents. This has been changed to lower case for ease of readability. October 1. 10/18/13-FALLS ASSESSMENT, fall with no injury. The fall was described as, "Resident walking with walker; student nurse following with the wheel chair, once in room resident stared (sic) to sit and tipped to the left. Student had a gaitbelt and lowered resident to the floor. Wheelchair was not locked as student nurse was positioning it behind the resident." Interventions listed as in place were, gait belt on, walking with student nurse. Changes to the care plan were listed as, "none." November 2. 11/25/13-FALLS ASSESSMENT, fall with an injury to the head. The fall was described as, "Resident standing by the table in the dining room. Went to sit in her wheel chair and wheelchair not locked and rolled away." The resident hit her head on the floor. The assessment also indicated there were no other injuries. Interventions listed as currently in place were; walk with assistance, uses walker, uses wheelchair. The assessment does not indicate if this was a witnessed fall or if staff were assisting the resident at the time of the fall. Changes to the care plan were listed as, "none." December 3. 12/1/13-FALLS ASSESSMENT, fall with injury. The fall was described as, "Resident was transferring herself from her w/c to her recliner. Stated 'I forgot to use the brakes'. Denies hitting her head." The assessment indicated there were no injuries. The assessment also described the resident as, "c/o right wrist pain." Under, "If injuries occurred, describe:," was written, "stiff wrist." The assessment described interventions in place as, "call light in reach." The assessment did not address care plan updates. 12/1/13-List Patient Notes described the fall as, "The resident was transferring herself from her w/c to her recliner. She stated "I forgot to use the brakes." The notes report, "ROM done with c/o pain." The notes indicated the resident described her wrist as, "a little stiff." 4. 12/4/13- FALLS ASSESSMENT, fall with no injury. No data surrounding the circumstance of the fall was included in the assessment. Interventions currently used included "call light in reach." Changes to the care plan were described as, "Needs more assistance to the bathroom." 12/04/13- List Patient Notes described the fall as, "Heard resident calling for help. Was found laying on left side of bathroom floor, states that she forgot to lock breaks on wheelchair. Denies hitting head and states that she has no pain...." 5. 12/25/13-FALLS ASSESSMENT, fall with injury. The circumstances surrounding the fall was described as, "Found on floor." The fall was unwitnessed. The resident sustained [REDACTED]. The resident was unable to report what she was doing at the time of the fall. The assessment did not include information regarding interventions currently in place and indicated no updates were made to the care plan. 12/25/13-List Patient Notes, refers the reader to the falls assessment for details and indicated the resident was sent to the ER for an evaluation. January 6. 1/14/14-FALLS ASSESSMENT, fall with injury. The circumstances surrounding the fall were described as, "Found on floor,

Based on observation, staff interview, and record review, the facility failed to provide services necessary to avoid physical harm, specifically related to multiple incidents of falls with major injury for 6 (#s 8, 10, 11, 22, 23, 24) out of 24 sampled and supplemental residents. Specific failures were: 1. Resident #8 had eight falls. Four of the falls occurred prior to the facility implementing new interventions to prevent future falls or injury from falls. The resident hit his head on three of the falls, two of these causing head abrasions. The facility failed to utilize the resident's fall history to develop an effective plan of care to prevent falls with injury. The facility failed to follow the resident's plan of care for fall prevention. 2. Resident #10 had 13 falls within the last year. For the first eight falls, six caused injury. The facility failed to implement specific interventions utilizing the resident's history of falls and causal factors. After each fall, the facility failed to revise the care plan to prevent future falls or falls with injury. For the most recent fall, staff failed to follow the resident's individualized care plan. The resident was unsupervised, fell , and sustained a fracture. 3. Resident #11 had 27 falls within the last year (between 5/20/13 to 6/3/14.) Fifteen of these falls were with injury. He had one [MEDICAL CONDITION], four injuries to the head (one being a contusion to the back of his head), four abrasions and 11 skin tears. The facility failed to utilize the resident's fall history to develop an effective plan of care to prevent falls. 4. Resident #22 had 12 falls since admission on 11/12/13. Eight of the falls were with injury. Record review indicated she was seen in theER on three occasions following falls. She sustained multiple skin tears, abrasions, lacerations to her forehead and nose, and hip pain. She was seen by an APRN in the facility for one fall, with a laceration to the back of her head. She sustained multiple skin tears and abrasions during falls that did not require an ER visit. The facility failed to utilize the resident's fall history to develop an effective plan of care to prevent falls. 5. Resident #23 had four falls within the last year. One of the falls resulted in a fracture of her hip. The facility failed to update the resident's plan of care for fall prevention related to mobility, ADL care, and document attempts to prevent future falls. The facility routinely disposed of the Pocket Care Plan, which in turn did not allow the facility to effectively show they attempted to prevent accidents with injury. 6. Resident #24 was not toileted immediately after meals resulting in multiple falls to include one fall that resulted in a major injury that required surgical intervention. IMMEDIATE JEOPARDY Six residents (# 8, 10, 11, 22, 23, 24) did not receive services necessary to avoid physical harm related to their fall risk. Staff failed to include interventions in the current care plan to prevent future falls. Staff did not actively follow and carry out interventions on the active care plan to prevent future falls. Six residents experienced falls with major injuries. On 6/6/14 at 2:30 p.m., the facility administrator and DON were notified by the survey team that an immediate jeopardy situation existed in the area of Quality of Care for 6 (#s 8, 10, 11, 22, 23, 24) sampled and supplemental residents that had experienced falls with major injury. The areas of deficiency included F224-neglect and F323-accidents and hazards. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to abate the immediate jeopardy on 6/6/14 at 12:50 a.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: Policy changes/additions: -the care plan included the Care Center Care Plan, the RAI (Kardex), and the Pocket Care Plan; -assessment will be done within 12 hours of admit, including steps required by admit; -plan of care will be reviewed after each fall to include assessment, review of the fall (evaluation of causal factors), develop a plan, communication of plan to staff, and documenting interventions; -falls will be re-evaluated by falls team and at total care meetings and will be adjusted with new interventions and communicated with staff per policy; -staff shall initiate appropriate interventions to address identified risk factors as per policy; -care plans must be revised after every fall with the interventions identified; and, -all Pocket Care Plans, Care Center Care Plans and RAI (Kardex) plans are considered part of the resident's record and shall be treated accordingly. They will be dated and retained and scanned into the facility Meditech electronic record. Communication changes/additions: -information will be shared at shift report; -specific individualized interventions will be added to the resident plan of care; -the administration will educate all employees of the necessity of following the Falls Policy; -the care plan will be revised and communicated to all staff for all changes made immediately and at change of shift along with the reviews by the Falls team; -the RN or LPN will complete the task of communicating changes to all staff at the end of each shift; -staff will be educated on the revisions to the care plan at staff shift report; and, -when the Pocket Care Plan, Care Center Care Plan, and RAI (Kardex) are revised, they will be scanned into Meditech by the appropriate staff per organizational access. Monitoring changes/additions: -RN/LPN will be responsible to monitor that each of the steps in the Falls policy are followed and report any variances to the DON. The DON will be responsible for overall monitoring of these corrections; -RN/LPN will be responsible to monitor that each of the steps in the Falls policy are followed and report any variances to the DON. Quality Action reports are reviewed with appropriate recommendations on a daily basis at administrative morning report. The DON will be responsible for the overall monitoring of the corrections; and, -Ward clerks will route the Pocket Care Plans, Care Center Care Plans, and RAI (Kardex)for scanning to the appropriate staff per organizational access. The DON will be responsible for the overall monitoring of these corrections. Specific corrective action for each of the 6 residents (#8, 10, 11, 22, 23, and 24) listed above were addressed as follows: 1. Resident #8 had changes to his care plan to include: -leaving his room door partially open for staff to visually see when passing; -ensure his position in bed is in the middle, with body pillow; -reminder to offer the use of the recliner after meals; -keep glasses clean and within reach at all times; -check often for incontinence; -observe for increased need for ADL assistance; -overhead light attached to pillow; -mattress to floor in case he falls from bed; -bed in low position; and, -overbed table near resident when in bed/chair. 2. Resident #10 had changes to her care plan to include: -turning and positioning schedule, and to reassess every two hours to determine if she needs to be repositioned; -if restless, investigate for potential pain issues; -encourage sitting positioning in television room in recliner, with shows she prefers; -if restless and is uneasily altered, enlist a one to one for an activity; -assistance of two people for transfers; -weight bearing precautions and new transfer status with slide board and gait belt; -wheelchair for transporting; -low bed, always while in bed; -bedside commode; -walker placement out of line of sight; -assistance with toileting, staff to stay within line of sight at all times; -poor awareness of safety needs; -additional detailed behaviors were added (not all inclusive); and, -frequent room checks for safety, keeping the door open for visual check of the resident. 3. Resident #11 had changes to his care plan to include: -check every 15 minutes to maintain safety of resident; -nurse will monitor this every hour and document showing this observation has been completed and properly documented; -assist of one with gait belt and walker to and from meals and with ADLs; and, -assess for weakness to ascertain as to whether wheel chair should be used. 4. Resident #22 had changes to her care plan to include: -Sara lift for transfers; -3-day bladder diary to evaluate effective toileting plan -toileting schedule to be established following the 3 day bladder diary; -Physical Therapy services; Balance Test performed by Physical Therapist. Recommends a Neurologist consult for Ataxia, order received by PCP on 6/5/14; and, -discuss with PT on 6/7 the appropriateness of size of wheelchair and use of wheelchair legs. 5. Resident #23 had changes to her care plan to include: -when in wheelchair, keep within sight of staff for safety; -place call light over bathroom door handle so it's within reach, and remind her of location; -Sara lift; -bladder diary to determine bladder habits and needs; -physical therapy consult for balance testing and size of wheelchair legs; and, -neurologist consult for ataxia. 6. Resident #24 had changes to her care plan to include: -for each meal she will be the last resident toileted on pre-meal rounds; -the timing of the meal tray delivery will be arranged to promote optimal duration of staff supervision; -the resident will be toileted upon completion of her meal and returned to the dining room to be offered additional fluids and provide resident socialization and staff oversight; -toileting will be carried out by all staff; -all staff will toilet resident #24 at the start of each shift and then every two hours; and, -all toileting will be carried out by all staff members. The correction plan was accepted and the immediate jeopardy was abated on 6/6/14 at 12:50 a.m. The deficient practice remained at the scope and severity of an H once the immediate jeopardy was abated. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, with an ARD of 3/4/14, coded resident #8 as needing extensive assist of one person for bed mobility, transfers, dressing, eating, toileting and personal hygiene. From 6/5/13 to 3/23/14, resident #8 had eight falls, four with injury. The falls occurred on: 6/5/13, 7/2/13, 9/13/13, 10/3/13, 10/31/13, 1/10/14, 3/6/14 and 3/23/14. Causes of the falls included: five falls from self transferring, two falls from rolling out of bed, one fall from reaching too far. After the resident's 6th fall, dated 1/10/14, the nurse implemented two interventions on the Fall Assessment form, which was a low bed and use of the call light. A fall mat was added to the interventions for the 7th fall on 3/6/14, per the Fall assessment form. This was again implemented as a new intervention on 3/23/14, per the Fall Assessment form. The Pocket Care Plan, which the CNA staff reported using daily, did not include the fall pad as a fall intervention. Resident #8's last two falls, on 3/6/14 and 3/23/14, resulted in two abrasions to his head, one with each fall. On 6/5/13, the Fall Assessment reflected that the resident was not to be left alone in his wheelchair in his room. On 6/5/14, 7/2/14, 9/13/13, and 10/3/13, the resident fell while unattended in his room and in his wheelchair. The care plan for resident #8 was comprised of three parts: -Pocket Care Plan (last revision not dated): The fall category for resident #8, had one intervention, "Geri chair for all meals." -Care Center Care Plan-last fall revision 3/23/14 This included the dates of the resident's falls, with the intervention to assess for injury with falls. -RAI (Kardex) Assessment-Care Area 11 Falls-last revision 3/5/14 The care problem was documented as cognitive loss and dementia. The causes included leaning, which caused him to fall. The resident's falls interventions were documented as, "Anticipate (resident's) needs as much as possible; Assist with all mobility needs." On 6/6/14 at 10:55 a.m., resident #8 was observed unattended in his room, sitting in his Geri chair. Staff member K, a CNA, who was assigned to resident #8 for the day, was interviewed on 6/6/14 at 7:35 a.m. She reported resident #8 used a Geri chair for meals only. He was unable to bear weight, and had a fall pad for fall prevention when in bed. Staff member K showed her Pocket Care Plan, which she used daily. Resident #8 was observed, unattended in his room sitting in his Geri chair. On 6/6/14 after breakfast resident #8 was observed throughout the morning, unattended in his room, sitting in his Geri chair. At 11:35 a.m., the CNA stated she had not returned the resident to his room after the morning meal and was unsure who did. She stated she had checked on the resident after breakfast, but she had to go to lunch. The resident's Pocket Care Plan, which the CNA had produced earlier, included documentation about not leaving the resident in his room in his Geri chair unattended. Staff member L, an RN, who was assigned to this residents care was interviewed on 6/6/14 at 11:05 a.m. She stated resident #8 can no longer push himself to meals, so staff assist him to and from the dining room. She indicated the CNA was at lunch. Staff member L stated she did not know why resident #8 was in a Geri chair throughout the morning. The facility policy titled, "Falls Protocol" with an effective date of 03/12, directed staff to assess a fall when it occurred and attempt to: Identify the cause of the fall, evaluate causal factors, determine interventions, and document interventions for future prevention. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10 had 13 falls documented on the Fall Assessment forms, between 12/3/13 and 5/28/14. Past falls included: 12/3/13-Resident reported a fall in bathroom/no injury; 12/28/13-Found on floor/skin tear right elbow, pain in right wrist; 2/23/14-Bent over and fell /skin tear to right forearm; 3/9/14-Self reported fall/bruising left shoulder; 4/8/14-Self reported fall off bed/hit head; 4/15/14-Getting out of bed and fell to knees/no injury; 4/16/14-Self reported fall off bed/hit head and had a headache, and her "bottom" hurt; 4/24/14-Self transferred with pants down and fell /pain to buttocks; 4/26/14-Attempted to sit, tipped chair and fell /no injury; 5/15/14-Walking and fell /skin tear to left elbow; 5/21/14-Walking and fell /hip pain; 5/22/14-Constantly moving from sitting to standing position and fell /pain from hitting head; 5/28/14-A staff member toileted the resident, then turned away, leaving the resident unattended. The resident got up from the toilet and walked with her pants down and fell . She suffered an abrasion to her low back and hip pain. The resident was sent to the emergency room and diagnosed with [REDACTED]. The resident's current care plan included an intervention not to leave the resident unattended on the toilet. Interventions located on the Fall assessment form included the following past and future interventions: 12/3/13-Blank/None; 12/28/13-Blank/N (none); 2/23/14-Blank/N (none); 3/9/14-Blank/N (none); 4/7/14- Observation/N (none); 4/15/14-Blank/N (none); 4/16/14-Observation/N (none); 4/24/14-Call light, toilet, encourage walker/low bed, monitor, stay with while toileting; 4/26/14-Call light, toilet, encourage walker/N (none); 5/15/14-Call light, low bed/Blank; 5/21/14-Call light, low bed/N (none); 5/22/14-Blank/low bed, monitor, stay with resident; and, 5/28/14-Low bed, stay with while on toilet, call light in reach/N (none). Review of the resident's fall documentation, did not show evidence of adequate investigation for the root cause of each fall, nor the implementation of interventions. The repeated falls continued to occur, and the interventions continued to be similar, without revision. The facility Fax Request Order form, dated 4/28/14 included, "PT to evaluate and treat, Dx (diagnosis) frequent falls." On 5/21/14, a Fax Request Order form was sent to the physician notifying him of another resident fall. The documented response on the fax communication, from the physician, included, "Pt (sic) to eval and treat for frequent falls unless already ordered. (Physician name) to see (sic) Dx: worsening anxiety." A physical therapy evaluation was completed on 4/29/14. This was for decreased functional mobility. The therapist documented the resident's history as: she had stopped using her 4 wheel walker, which she had been independently using up to two months prior; had increased falls; shuffled her feet when walking; and, unable to respond as well when communicating. The treatment plan for physical therapy was discontinued as of 5/9/14 due to the resident reaching her prior level of functioning. The therapist documented, "Pt (sic) ignores verbal cues for safety...continuing to make her high fall risk. With her dementia she is unable to follow an exercise program. Staff instructed to cont (sic) amb (sic) program..." The facility care plan included three components, which were, The Pocket Care Plan, the Care Center Care Plan, and the RAI (Kardex). The Pocket Care Plan (last revision was not dated) included the following: Under the Safety Devices, Falls/Elopement, documentation included, "Multiple falls, bed in lowest position, stay with (resident) while on toilet." The RAI (Kardex) with the last falls revision dated 5/28/14 included the following: under Care Area #11- Falls, the documentation included, "See [MEDICAL CONDITION] drug use CAA." The [MEDICAL CONDITION] drug CAA was dated 4/11/14. Review of Care Area #17, [MEDICAL CONDITION] drug use, included the documentation, "Ms. (resident) has two reported falls in the past quarter. One in February with a small skin tear and one in March where she had bruising of unknown origin and she told staff she had fallen. No falls witnessed and no other injuries identified." A goal for the resident's falls included, "(Resident) will remain free from injury related to falls during the next quarter." The intervention for this plan included, "Keep room free from clutter and trip hazards." The ADL Functional/Rehabilitation Potential, care area #5 included: independent with transfers; independent with ambulation to and from the bathroom and to and from the dining room; continued to use four wheeled walker for stability; was independent with locomotion; and was independent with dressing and toileting needs. The Care Center Care Plan with a fall revision dated 4/11/14, included in the ADL category; "Falls; Resident placing self on floor stating the floor is cooler and prefers that at times. This is a planned event; Document with each fall." The dates of the resident's previous falls were included on the care plan. During the time span of 12/2/13 to 5/22/14, resident #10 had 20 physician ordered medication changes to her antidepressant, hypnotic, antianxiety, anticonvulsant, Parkinson and antipsychotic medications. Staff member J, CNA, was interviewed on 6/4/14 at 8:30 a.m. Staff member J was assisting resident #10 in the bathroom when the fall on 5/28/14 occurred. She stated, "I turned for just a second, went to grab the wipes...she got up and went right past me...fell there (pointed outside the bathroom by the resident's bed and wheelchair), her pants were down (pointing to her ankles), and she tripped. They sent her to the ER." The CNA stated the resident, "Plops down," when sitting. She reported the resident has a low bed, gets agitated, has to urinate often, uses her light to call for help, and needs frequent reminders due to poor cognition. Staff member J was utilizing a copy of the resident's Pocket Care Plan, which she carried in her uniform pocket. The Pocket Care Plan included the documentation not to leave the resident unattended on the toilet. A review of the Fall Committee meeting minutes, dated 8/13-4/14, lacked resident specific information for the prevention of falls. The committee began reviewing the fall process on August 23, 2013 in an attempt to decrease the number of falls. The May 2014 meeting minutes did include resident specific information, which was nine months after the committee began reviewing the fall process. Resident #10 was not included in the May meeting minutes. 3. Resident #11 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident resided on the locked special care unit. The resident had resided there since 8/13 when he had been moved with family approval due to aggression towards his wife and exit seeking behavior. He had resided with her on another unit of the facility. Review of the Minimum Data Set with the ARD of 4/2/14 indicated the resident was an extensive assist of one person with his ADLs. During an interview on 6/2/14 at 11:15 a.m., staff member G, an RN, stated, "(resident #11) was moved from west unit to the special care unit 6 months ago. He had some fighting with his wife. With his ADL's he is an assist of one or two. He is resistive at times with this assistance. He foot propels his wheelchair. Sometimes uses a walker. He feeds himself." The resident's room was observed to be clutter free on 6/2, 6/3, 6/4 and 5/14. During an interview on 6/3/14 at 9:12 a.m., staff member G, a registered nurse, indicated resident #11 had fallen during the night and knew the resident had not hit his head by the way he was positioned on the floor. She indicated the resident had good Neuros and good vitals. The fall had not been witnessed. a. Documented injuries from falls. The falls assessments and faxed request for orders were reviewed. These documents indicated the resident had 27 falls documented for the time range of 5/20/13 to 6/4/14. The following were the falls with injury during this period: -5/20/13 was an unwitnessed fall in his bedroom. The resident sustained [REDACTED]." The resident was sent to ED due to his complaints of hip pain. The resident returned from the ED with a [MEDICAL CONDITION]. -7/12/13 was an unwitnessed fall. The resident received a skin tear to his right shoulder. -7/13/13 the resident fell in the hallway. The resident sustained [REDACTED]. -7/21/13 was an unwitnessed fall. The resident received a skin tear to right inner forearm. -9/8/13 fell while standing over the toilet. The resident sustained [REDACTED]. -10/17/13 was an unwitnessed fall. The resident sustained [REDACTED]. There was a dark purple bruise around the skin tear. -11/10/13 resident fell backwards coming from nourishment room. The resident hit his head. The resident received a skin tear on his cheek and a bruise on the anterior aspect of his right arm. -12/24/13 the resident fell trying to get his door open. This resulted in a skin tear to his left elbow. -12/25/13 received a skin tear from this fall. -2/17/14 the resident was sitting on his chair and fell backwards. This resulted in a contusion to the back of his head. -3/6/14 was an unwitnessed fall in his bedroom. This resulted in a skin tear to his right forearm with a dark bruise around it. -3/11/14 the resident lost his balance after turning his walker coming from his room. This resulted in 2 skin tears to his knuckles with a dark bruise on 3 of the knuckles. -3/26/14 (at 3:25 p.m.) was an unwitnessed fall in his room. The resident had a reddened cheek. -3/26/14 (at 8:00 a.m.) fell out of bed. This resulted in a small abrasion to his left great toe. -4/11/14 rolled out of bed. This resulted in a large skin tear to his upper arm. -4/17/14 was found beside his bed. This resulted in an abrasion to his back and left shoulder. c. Review of the falls assessments for the period of 6/4/14 to 5/20/13 included suggested changes and interventions that were indicated to be in the CC Care Plan. These suggested changes and interventions were noted on: -7/13/13 Interventions that were in place at the time of the fall: "other" Were interventions effective? "yes" New interventions implemented as a result of this fall? "yes, close observation." -9/8/13 Interventions currently used to prevent falls: "Monitoring. Res. up independently." Changes to the care plan as a result of this fall: "Stay with res. when using the toilet." -1/3/14 Interventions in place at the time of fall: "Monitor closely Observation" -2/17/14 Interventions in place at time of fall: "Monitor closely Observation" Interventions currently used to prevent falls: "Continue to monitor GCS for fall 10/3 and again 10/8. Encourage resident to sit with other residents and staff supervision as much as possible." -3/3/14 Interventions in place at time of fall: "Monitor closely Observation" -3/6/14 Interventions in place at the time of fall: "Monitor closely Observation" -3/11/14 Interventions in place at time of fall: "Monitor closely observation" -3/26/14 Interventions in place at time of fall: "Observe for possible falls especially when getting up" -6/3/14 Interventions in place at time of fall: "Low bed frequent checks." Review of the Care Center Care Plan (CC Care Plan) on 6/4/14 indicated the resident had a goal to not fall over the next quarter. The plan included that staff would assist with activities of daily living as needed and to offer a clutter free environment. The above noted interventions had not been included in the CC Care Plan to address falls. During an interview on 6/6/14 at 5:40 p.m., staff member CC, an RN stated, "I thought the revisions to the plan were in the kardex, but they are not. (resident #11)'s pocket care plan needs to be updated. He no longer lives on west. He's at a place now where he needs an assist of one, not frequent checks. He has declined out of walker. He was doing a walker, now it's a wheelchair." At this time staff member CC was observed to mark out the walker on the pocket care plan and write in wheelchair. When asked about how long ago this decline occurred, staff member CC states, "I hate to put a number on it. He's been brought to the dining room the last 2 weeks." Review of the policy to reduce falls with a revision date of 3/12 included the procedure to have individualized interventions added to the resident's care plan to help decrease frequency of falls and minimize injury with falls. During an interview on 6/6/14 at 6:52 p.m., staff member DD, a CNA, when asked if he felt there were a lot of falls at the facility and why, stated, "Too many. Not specifically trained to deal with falls. Our problem is we don't know where fall risk are at. We have a tendency to get stuck in the dining room and can't see what's going on elsewhere on the unit." 4. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. A review of the MDS with an ARD of 11/13/13 showed evidence resident #22 had a history of [REDACTED]. A review of the MDS with an ARD of 2/6/4 showed evidence resident #22 had two or more non-injury falls, and two or more falls with injury in the first quarter (J1800 A and B). A review of the MDS with an ARD of 5/1/14 showed evidence resident #22 had two or more non-injury falls, and two or more falls with injury in the second quarter (J1800 A and B). The following forms, labeled FALLS ASSESSMENT, Falls Assessment, and List Patient Notes, were reviewed and contained the following information: Note: The falls assessments and list patient notes were written in all capital letters on the original documents. This has been changed to lower case for ease of readability. October 1. 10/18/13-FALLS ASSESSMENT, fall with no injury. The fall was described as, "Resident walking with walker; student nurse following with the wheel chair, once in room resident stared (sic) to sit and tipped to the left. Student had a gaitbelt and lowered resident to the floor. Wheelchair was not locked as student nurse was positioning it behind the resident." Interventions listed as in place were, gait belt on, walking with student nurse. Changes to the care plan were listed as, "none." November 2. 11/25/13-FALLS ASSESSMENT, fall with an injury to the head. The fall was described as, "Resident standing by the table in the dining room. Went to sit in her wheel chair and wheelchair not locked and rolled away." The resident hit her head on the floor. The assessment also indicated there were no other injuries. Interventions listed as currently in place were; walk with assistance, uses walker, uses wheelchair. The assessment does not indicate if this was a witnessed fall or if staff were assisting the resident at the time of the fall. Changes to the care plan were listed as, "none." December 3. 12/1/13-FALLS ASSESSMENT, fall with injury. The fall was described as, "Resident was transferring herself from her w/c to her recliner. Stated 'I forgot to use the brakes'. Denies hitting her head." The assessment indicated there were no injuries. The assessment also described the resident as, "c/o right wrist pain." Under, "If injuries occurred, describe: "stiff wrist." The assessment described interventions in place as, "call light in reach." The assessment did not address care plan updates. 12/1/13-List Patient Notes described the fall as, "The resident was transferring herself from her w/c to her recliner. She stated "I forgot to use the brakes." The notes report, "ROM done with c/o pain." The notes indicated the resident described her wrist as, "a little stiff." 4. 12/4/13- FALLS ASSESSMENT, fall with no injury. No data surrounding the circumstance of the fall was included in the assessment. Interventions currently used included "call light in reach." Changes to the care plan were described as, "Needs more assistance to the bathroom." 12/04/13- List Patient Notes described the fall as, "Heard resident calling for help. Was found laying on left side of bathroom floor, states that she forgot to lock breaks on wheelchair. Denies hitting head and states that she has no pain...." 5. 12/25/13-FALLS ASSESSMENT, fall with injury. The circumstances surrounding the fall was described as, "Found on floor." The fall was unwitnessed. The resident sustained [REDACTED]. The resident was unable to report what she was doing at the time of the fall. The assessment did not include information regarding interventions currently in place and indicated no updates were made to the care plan. 12/25/13-List Patient Notes, refers the reader to the falls assessment for details and indicated the resident was sent to the ER for an evaluation. January 6. 1/14/14-FALLS ASSESSMENT, fall with injury. The circumstances surrounding the fall were described as, "Found on floor, unable to tell staff what she was doing at the time of fall." This was an unwitnessed fall that resulted in a laceration to the back of the head. The interventions in place at the time of the fall was listed as, "call for assist." Changes to the care plan was listed as, "resident out of wheel chair between meals." 1/14/14-List Patient Notes, described the fall as, "Called to room by CNA, Resident coud (sic) be heard yelling for help. Resident found on floor, states that she 'cracked her head good'. Resident unable to tell staff what she was doing before she fell . when (sic)asked about pain resident states that nothing really hurts. Hand grips are srong (sic) and equal, pupils reactive to light, equal in size. VS at time of all (sic) .... When sitting resident up a 6 inch diameter puddle of blood was found under her head. Unable to find where blood is coming from. (advanced practice registered nurse) here and looked at resident head; wound with 500 ml NS (sic), steri strips on laceration, ...." The assessment also indicated a doctor gave new orders for pulse-ox while sleeping, and to put the resident on oxygen three liters if saturations go below 89%. 7. 1/22/14-F

Based on observations, resident and staff interviews, and record review, the facility failed to self identify quality of care issues, and failed to prevent harm and/or potential harm to residents. Sixteen (#s 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 22, 23, 24) of 24 sampled and supplemental residents were identified to be affected by the lack of an effective quality assurance system at the facility. Findings include: 1. IMMEDIATE JEOPARDY RELATED TO CARE OF RESIDENTS On 6/6/14 at 2:30 p.m., the facility administrator and DON were notified by the survey team that an immediate jeopardy situation existed in the area of Quality of Care for 6 (#s 8, 10, 11, 22, 23, 24) sampled and supplemental residents who had experienced falls with significant injury. Deficient practice included F224-neglect and F323-accidents and hazards. 2. ABUSE-RESIDENT BEHAVIOR AND FACILITY PRACTICE F224 Neglect The facility failed to identify and implement individualized interventions for six residents (8, 10, 11, 22, 23, 24) who were at risk for falls, had falls with injury, or had potential for injury from a fall. The facility neglected to: consistently investigate the cause of the falls; analyze risk factors surrounding the falls; interpret the effect of the falls on the resident; develop new individualized interventions; and revise the plan of care. Refer to F224. F225 ABUSE INVESTIGATION AND REPORTING The facility failed to investigate and report allegations of abuse for one resident (#10), and determine if the allegations required corrective action. Failure to investigate the allegation, did not allow the facility to identify if the concerns met the criteria state abuse reporting. Refer to F224/225. 3. QUALITY OF CARE F314 TREATMENT AND SERVICES TO PREVENT PRESSURE SORES The facility failed to accurately document the description, ongoing treatment, and progression of wounds for 2 resident (#s 8 and 9) and skin tears for one resident (#10). F323 ACCIDENTS AND HAZARDS In August of 2013, the facility quality assurance committee, developed a sub committee to evaluate the process for falls. On 8/23/13, the goals of the committee were: -Falls interventions in place. -Decrease number of falls per 1000 resident days. -Keep falls safe. -Reduce falls. -Find out the reason for falls. -Identify those residents at risk for falls, and reduce preventable falls. The team discussed the definition of a fall, tools used for the documentation of a fall, what was working when a fall occurred, and follow up needed. The Falls Team met on 8/28/13, 9/4/13, 9/11/13, 10/2/13, 10/23/13, 10/30/13, 11/13/13, 1/8/14, 1/22/14, 2/19/14, 3/5/14, 3/19/14 and 5/15/14. For the meeting held on 5/15/14, individual resident's were discussed to include their last fall date and current plan. Individual residents were not discussed, per the meeting minutes, prior to May 2014. On 6/6/14, a listing of resident's with major injuries from falls was requested. The listing included 21 individuals with falls between 5/20/13 and 3/4/14. Six resident's sustained injury, four with fractures. During the survey process, 6 (#s 8, 10, 11, 22, 23, 24) of the sampled and supplemental residents, were identified to have had a major injury. Refer to F323. F329 UNNECESSARY MEDICATION The facility failed to adequately monitor resident medications, failed to provide adequate education of the risks and benefits of medication, and failed to obtain written consent for specific medications for 3 (#s 7, 9 and 10) residents. 4. RESIDENT ASSESSMENT F274 SIGNIFICANT CHANGE The facility failed to identify changes in condition for one resident, (#10). The changes in resident #10 resulted in a decline in medical condition. The facility did not investigate the potential cause of the changes; failed to utilize the resident's individualized data to manage risk factors that caused increased risk of injury; and failed to update the residents plan of care as the changes occurred. Refer to F274 F279 CARE PLANNING REVISION The facility failed to periodically review and revise the care plan after each assessment and/or change of condition for 11 (#s 1, 4, 7, 10, 11, 12, 13, 14, 15, 22, 23) residents. The facility failed to integrate into the residents plan of care, the results of investigation, potential barriers, outcomes, goals and interventions. The facility failed to implement resident specific goals. Refer to F279. 5. ADMINISTRATION F515 RETAIN CLINICAL RECORDS The facility failed to maintain portions of the comprehensive care plan for all resident's at the facility. The destruction of documents prevented the facility from producing the necessary resident information during the recertification survey. Refer to F515.