Every finding on record at Oakmont Healthcare and Rehabilitation Center of Ka

Based on observation, interview and record review, the facility failed to ensure residents have a right to a dignified existence and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #41) of 18 residents reviewed for dignity.-RN Z was providing Resident #41's bolus feeding with the door open and blinds opened on 02/25/2026.- RN Z did not provide Resident #67 privacy during insulin administration on 02/25/26.-LVN AF did not provide privacy during medication administration via G Tube to Resident #30 on 2/24/26These deficient practices could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition. Resident #41Record review of Resident #41's face sheet last captured 02/26/2026, she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnosis was gastronomy status (has a gastrointestinal tube to provide nutrition and medication from opening straight into stomach).Record review of Resident #41's Order Summary Report dated 02/26/2026, she had active orders with a start date of 02/04/2026 for: enteral (through gastrointestinal tube) feed order four times a day Isosource 1.5 @ 50 ml/hr for 5 hours then 1 hr bowel rest and four times a day water flush 250 mls.Observation and interview on 02/25/2026 at 4:08pm, RN Z was observed providing water flush for Resident #41 with the door open and curtain not pulled during the procedure. RN Z was observed letting water flush by gravity. Resident #41's head was turned toward the window, and she did not appear to be in any discomfort. RN Z stated that she should have pulled the curtains which she usually did but she was unsure why she did not pull the curtains that day. RN Z said it would not make residents feel good to know that others were watching their procedures. Attempted interview with Resident #41 on 02/26/2026 at 4:19pm, she appeared to be sleeping and comfortable in bed with no respiratory distress. Resident #67 Record review of Resident #67's face sheet, dated 2/24/2026, reflected the resident male, and admitted to the facility on [DATE] readmitted on [DATE] with a diagnosis of type 2 diabetes mellitus with diabetic neuropathy.Record review of Resident #67 's quarterly MDS, dated [DATE], reflected the BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #67 was incontinent to bladder and bowel. Record review of Resident's #67's care plan, dated 12/24/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.During observation of East wing nurse's medication cart parked on the hallway by the main dining room on 2/25/26 at 4:39PM, RN Z was by the medication cart. Resident #67 was propelling himself by wheelchair on the hallway, RN Z stopped Resident #67 by the medication by the cart, picked the accu check machine (machine used to measure blood sugar levels), checked Resident #67's blood glucose and picked up Humalog Kwik pen (Insulin) and opened the resident's shirt and administered to his abdomen. There were residents going by toward the dining room for dinner.Interview with RN Z on 2/25/26 at 4:44 PM RN Z said she always checked blood glucose before residents go to the dining room and she did not think it was wrong.Resident #30Record review of Resident #30's face sheet dated 02/24/26 revealed a [AGE] year-old male was admitted on [DATE] and re-admitted on [DATE]. Resident #30 had a diagnosis of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach)Record review of Resident #30's admission MDS, dated [DATE], reflected the BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent in bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #30 was incontinent to bladder and bowel. Record review of Resident #30's care plan dated 12/24/25 reflected Resident #30 has an ADL self-care performance deficit; the goal was resident will improve current level of function through the review date:Record review of Resident #30's Physician's Orders, dated 02/1/26, reflected the following orders: Had NPO (Nothing per oral) only GT: Bolus give 1 can Isosource 1.5 five times a day. Check for residual every shift if > 150cc 's, stop feeding and notify MD every shift. Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift.Observation of medication administration on 2/24/26 at 9:40AM LVN AF did not pull the privacy curtain. Resident #30 was lying on the bed and was visible from the hallway. LVN AF aspirated 58ml of milky fluid and pour it in a cup, then aspirated additional 30 mls milky fluid via G Tube, LVN AF the plunge it via G Tube to Resident #30's stomach and then aspirated 58 mls in the cup and plunge it via G Tube LVN AF aspirated Lacosamide 100 mg 1 tablet after crushing it and Polyethylene Glycol 3350 (17gm) dissolved in water in 60 mls syringe and plunged via Resident #30's G-Tube.Interview on 2/26/26 at 10:15AM LVN AF said she forgot about providing privacy and will be careful.Interview with the Administrator and DON on 02/25/206 at 5:35pm, the Administrator said that privacy curtains should be utilized during procedures. Residents having procedures done without them could have made them feel uncomfortable and not have privacy. Record review of the facility's policy on resident rights, undated, read in part, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Privacy and confidentiality .1. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits.

Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the residents' status for 2 of 18 residents (CR #75 and Resident #60) whose assessments were reviewed, in that:-CR#75's behavior was not reflected on her initial MDS dated [DATE]. -Resident #60's fall on 10/15/2026 was not documented in her most recent quarterly MDS assessment on 11/29/2026.These failures could place residents at-risk of not receiving the care and services to prevent aggressive behavior or injury due to inaccurate assessments. #75 Record review of CR#75's clinical records dated 2/24/2026 revealed she was a 76-year female who was admitted to the facility on [DATE]. Her diagnoses included Non-Alzheimer's dementia (memory loss), dysphagia (swallowing difficulties), depression (feeling of unhappiness and hopelessness), respiratory failure (condition where the blood does not have enough oxygen or too much carbon dioxide), pain (unpleasant sensory and emotional experience with tissue damage), and altered mental status (a change in mental function), chronic obstructive pulmonary disease (disorder of the lungs and airway disease that restrict breathing), muscle weakness (loss of muscle function). Record review of CR #75 admission MDS dated [DATE] Section C, 500 revealed the resident had a BIMS score of 10 of 15 indicating she was cognitively aware. For Section E200: she was coded as having no behavior. Record review of the nurse's progress notes from January 2026 indicated the following dated:1/06/2026: CR #75 refused to eat, stating she was not hungry and did not like the food.1/10/2026 at 1:38 am CR #75 resident out of bed screaming and yelling.1/10/2026 at 1:34 pm CR#75 acting very agitated cursing staff, kicking walls and throwing things on floor.1/11/2026 CR#75 refused care and breathing treatment. Record review of CR #75 care plan initiated on 1/6/2026 was not review and revised to address the resident behavior of refusing to eat, refusing care and treatment, screaming and yelling, cursing at staff, kicking walls and throwing things on the floor.Resident #60Record review of Resident #60's face sheet dated 02/26/2026 reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included unspecified dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), muscle weakness, Schizoaffective Disorder (a mental health condition that is marked by hallucinations and delusions and mood dysfunction), extrapyramidal and movement disorder (drug-induced muscle disorder with symptoms including involuntary muscle contractions or repetitive movements) and history of falling. Record review of Resident #60's Quarterly MDS dated [DATE], she had a BIMS score of 04, indicating severe cognitive impairment related to thinking and memory. She required total assistance with toileting, footwear and substantial assistance with dressing, personal hygiene and substantial assistance with most mobility in bed. Resident #60 was coded as having no falls since the last quarterly assessment. Record review of Resident #60's falls in the Incident report last updated 02/24/2026, indicated Resident #60 had a fall on 10/15/2025.Record review of Resident #60's progress notes dated 10/15/2025 at 1:20pm Resident #60 was documented by LVN BN as sitting on her bottom on the floor.The patient states she put her feet on the floor and slipped down to her bottom. She was assessed for injuries with none noted. No complaints of pain at this time. Interview on 2/26/2026 at 3:38pm with the MDS Coordinator AK said, she was new to the facility and was working on MDS and care plan issues. She said when she completes the MDS she reviewed the nurse's notes; interviewed staff and observed residents. She stated CR#75 MDS was coded incorrectly. She was not the one who does the behavior section of the MDS. She said social service usually does that section. She said if the residents had behavior issues it should be documented on their MDS. MDS Coordinator AK said Resident #60's fall on 10/15/2025 should have been documented in her most recent Quarterly MDS on 11/29/2025 as it was within the 3-month lookback period. MDS audits were done by the MDS Coordinator and Regional MDS staff. Falls should be documented and modified MDS forms could be sent in if needed. In an interview with SW on 2/26/2026 at 4:00pm she said she was new to the facility and has not done any MDS. She said the social worker usually do the behavior section. She said to complete her MDS she checks the nurse's notes, observes residents, interviews the CNAs, and interviews the nurses. She said at that point she would complete her section of the MDS. She said the care plan should be updated to address the resident's current condition. In an interview with the Regional Nurse on 2/26/2026 at 4:33pm he said the person doing the MDS should talk to the nurses and CNA's and observe residents and complete assessments before documenting the MDS. He said the MDS nurses were responsible for the accuracy of MDS's. The Regional Nurse said that if behaviors or falls were not documented accurately in residents' MDS then they would not have the right interventions in place to prevent injuries or further falls. Record review of the facility's policy on MDS Assessment Data Accuracy dated 08/2025, it read in part, Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status. 2. A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals. 3. The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 20%, based on 7 errors out of 35 opportunities, which involved 2 of 7 residents (Resident #30, and Resident #6) and --2--- of ---3-- staff observed during medication administration reviewed for medication errors. 1. LVN AF failed to administer Polyvinyl Alcohol-Povidone PF Ophthalmic Solution 1.4-0.6 % (used to temporarily relieve dry, burning, itchy, or irritated eyes by wind, sun or environment) lower high fluid pressure inside the eye) Ophthalmic Solution 0.5 % eyedrops ophthalmic drops, on 2/24/26, initialed as given to Resident #30, when it was not given.2. LVN AF failed to administer Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tab (used to treat gastric reflux) on 2/24/26, initialed as given to Resident #30, when it was not given. 3. LVN AF failed to administer QUEtiapine Fumarate Oral Tablet 50 MG (Used to treat mental health conditions by balancing neurotransmitters in the brain) Give 1 tablet via G-Tube two times a day for Schizophrenia on 2/24/26, initialed as given to Resident #30, when it was not given. 4. LVN AF failed to administer Ascorbic Acid Oral Tablet 500 MG (used water-soluble nutrient and essential antioxidant that the body needs) Give 1 tablet via G-Tube one time a day for Supplement on 2/24/26, initialed as given to Resident #30, when it was not given. 5. LVN AF failed to administer Thiamine HCl Oral Tablet 100 MG (an essential nutrient that helps your body convert food) (especially carbohydrates) into usable energy) Give 1 tablet via G-Tube one time a day for Supplement on 2/24/26, initialed as given to Resident #30, when it was not given. 6. LVN AF failed to administer Olanzapine oral (used to treat schizophrenia and bipolar disorder) tablet 5 mg every day on 2/24/26, initialed as given to Resident #30, when it was not given. 7. RN W failed to administer on 2/24/26, Carb/Levo10-100 mg (used to treat the symptoms of Parkinson's disease) was not given in totality and was initialed as given to Resident #30. These failures could place residents at risk for increased negative side effects, and a decline in health. 1. Record review of Resident #30's face sheet, dated 02/24/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #30 had diagnoses which included: iron deficiency anemias (not having enough healthy red blood cells to carry oxygen to the body's tissues), anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (blood vessels is too high), heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids), Parkinson's disease (progressive neuro degenerative disorder, not a condition with a functional use. It involves the death of brain cells that produce dopamine), gastro-esophageal reflux disease without esophagitis (gastric reflux), hemiplegia and hemiparesis (the severe or total paralysis one side of the body) following cerebral infarction (blood flow blocked to part of the tissue of the brain resulting to tissue dying due to a lack of oxygen and nutrients) affecting right dominant side, chronic kidney disease (cannot properly filter waste and extra fluid from your blood, causing toxins to build up), dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), essential (primary) hypertension (high blood pressure), heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), hypokalemia (lower than normal potassium level in the bloodstream), dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach). Record review of Resident #30's admission MDS, dated [DATE], reflected the BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment. The resident was totally dependent on bed repositioning and personal hygiene. Resident #30 was incontinent to bladder and bowel. Record review of Resident #30's care plan, dated 12/24/25, reflected Resident #30 had an ADL self-care performance deficit, the goal was resident will improve current level of function through the review date: Resident #30 required total assist with one to two person for bathing/showering, dressing, bed mobility, personal hygiene, toilet use and follow principles of infection control and universal precaution to incontinent care. Record review of Resident #30's Physician order, dated 2026, reflected in part:-2/6/26 had Polyvinyl Alcohol-Povidone PF Ophthalmic Solution 1.4-0.6 % (Polyvinyl Alcohol-Povidone (Ophth) Instill 1 drop in both eyes two times a day for Lubricant-2/9/26 had Protonix Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth two times a day for esophagitis-1/26/26 had Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet via G-Tube two times a day for Schizophrenia-1/26/26 had Ascorbic Acid Oral Tablet 500 MG (Ascorbic Acid) Give 1 tablet via G-Tube one time a day for Supplement-1/26/26 had Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet via G-Tube one time a day for Supplement.-2/6/26 had Olanzapine oral tab 5 mg QD. Give 1 tablet via G-Tube one time a day for Schizophrenia (a chronic, severe brain disorder that causes people to interpret reality abnormally) Record review of Resident #30's MAR, dated 2/24/2026, reflected in part . Olanzapine oral tab 5 mg, Ascorbic Acid Oral Tablet 500 MG, Thiamine HCl Oral Tablet 100 MG, Quetiapine Fumarate Oral Tablet 50 MG, Protonix Tablet Delayed Release 40 MG and Polyvinyl Alcohol-Povidone PF Ophthalmic Solution 1.4-0.6 % was initialed as given via G-Tube in AM. Observation of medication administration on 2/24/26 at 9:40 AM by LVN AF revealed LVN AF gave Lacosamide 100 mg 1 tablet after crushing it and Polyethylene Glycol 3350 (17gm) dissolved in water and administered via Resident #30's G-Tube did not flush with GTube before and after medication with water. LVN AF plunged medication via tub, did not allow it to flow by gravity. Interview with LVN AF on 2/24/26 at 9:35AM, before administering medication Resident #30, LVN AF said she administered Resident #30's blood pressure medication only and his bolus feeding via GT because the blood pressure was too high BP 197/102 and pulse at 77. LVN AF said she was going to medicate with the rest of Resident #30's medication, and she went to resident room, did not close the door, did not wear PPE while administering the medication. Interview on 2/26/26 at 10:15AM with LVN AF revealed she only gave Resident #30 two medications via G Tube for his blood pressure. LVN AF said she gave the BP medication earlier because the BP was high, she already gave the resident the BP medications through bolus feeding. The LVN only gave 2 medications because he had a lot of blood pressure medications. LVN AF did not give any response to all medications initialed as given when it was not given during medication administration and not closing the door. 2. Record review of Resident #6's face sheet, dated 2/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #6 had diagnoses which included: hyperlipidemia ( high lipid/fat in the blood), anemia, diabetes mellitus (high glucose in the blood), essential (primary) hypertension (high blood pressure), heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), Parkinson's disease without dyskinesia, without mention of fluctuations, contracture, left hand(m), dementia (decline in thinking, remembering, and reasoning), gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), glaucoma (high fluid pressure inside the eye) and protein-calorie malnutrition. Record review of Resident #6's quarterly MDS assessment, dated 1/30/26, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required total assistance from staff with ADL's care. Record review of Resident #6's physician order for 2/1/2024 revealed in part . Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa) Give 1 tablet via PEG-Tube three times a day related to Parkinson's Disease without Dyskinesia, without mention of fluctuations. Record review of Resident #6's physician order for February 2026 revealed in part . Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa) Give 1 tablet via PEG-Tube three times a day. During an observation on 2/24/26 at 12:50 p.m., revealed RN W punched 1 tablet of Carbidopa-Levodopa Oral Tablet 10-100 MG into a medication cup, crushed it and diluted with 15mls of water and dissolved and administered it via GT. RN W was about to discard the medication cups with a substantial amount of Carbidopa-Levodopa Oral Tablet 10-100 MG residual left. The state surveyor intervened after showing RN W the Carbidopa-Levodopa Oral Tablet 10-100 MG left in the medication cup. RN W said, I will give it. She then poured 10mls of water and Carbidopa-Levodopa Oral Tablet 10-100 MG to administer in via GT. Interview with RN W on 2/24/26 at 1:10 PM, regarding not administering all Carbidopa-Levodopa Oral Tablet 10-100 MG, she said she would be careful. She knew Carbidopa-Levodopa Oral Tablet 10-100 MG not given in totality would cause forgetfulness or confusion and constipation. In an interview with the Regional Nurse on 2/26/26 at 2:38 PM, revealed her expectation for medication administration was for nurses to administer medication as ordered by the physician. The Regional Nurse said the facility had AM medication pass times to 6:00 AM to 10:30 AM and if the state surveyor did not observe medications given 2/24/2026 in the AM, he could not defend it. He said the DON always monitored the staff periodically and the pharmacist also monitored the staff. The last time the pharmacist monitored staff was in November 2025 In an interview on 2/26/26 at 2:40 PM, the Administrator said she expected nursing staff to give medications timely, correctly, and according to the physician orders. Record review of the facility's Administering Medications policy, updated 3/2024 revealed in part Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. Record review of the facility's medication administration updated 3/2024 MED - PASS, Inc reflected in part . Medications are administered in a safe and timely manner, and as prescribed . Record review of the facility's policy on administering medications through an enteral tube, updated 3/2024, reflected in part .Purpose . the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food past the use date was discarded. 2. The facility failed to ensure leftover food to be used later was stored at a safe temperature.3. The facility failed to ensure frozen food thawed properly. 4. The facility failed to put sufficient sanitizing solution in the 3-sink compartment in the kitchen.5. The facility failed to fix broken tiles in the kitchen.6. The facility failed to store in a separate container a scoop used for food bins in the kitchen storeroom.7. The facility failed to ensure food was stored 6 inches off the floor These failures could place residents t risk of foodborne illness, disease from food handling and pest or vermin. Observation of the facility kitchen on 02/24/2026 at 8:45 AM revealed the following. 1. Thawing frozen chicken in an 8-inch-deep bucket, immersed in water that was 78 degrees Fahrenheit in the sink, measured by the Dietary Food Service Manager.2. A pan of mechanical soft sausage was 131.1 degrees Fahrenheit on the steam table.3. A pan of breakfast sausage with a used by date of 2/13/2026 was in the fridge. 4. A pan of Salisbury steak with a use by date of 1/7/2026 was in the walk-in fridge. 5. An open package of shredded cheddar cheese with no used by date was in the walk fridge. 6. An open package of sliced Swiss cheeses with no use by date was in the walk-in fridge. 7. 1 case of frozen ground beef was in the walk-in freezer on the floor. 8. 2 cases of fruit cocktail were on the storeroom floor.9. One trayful of milk was at 46.5 degrees Fahrenheit and one trayful of cranberry juice was at 53.4 degrees Fahrenheit on the serving lunch table. 10. 2 lunch dialysis bags with respective used by dates of 2/11/2026 and 2/13/2026.11. A pan of corn niblets were in the walk-in fridge did not have date opened and date discarded labelled on the item.12. The 3- Sinks compartment did not have enough sanitizing solution in the kitchen. The sink was currently in use. When the Dietary Food Service Manager used a strip of paper to measure amount in the solution, it was an insufficient amount to clean the pots and pans currently in the sink.13. The kitchen floors and walls had several broken tiles with openings in the kitchen. In an interview with the Dietary Food Service Manager on 02/07/2026 at 8:45 AM, she stated the following foods were stored in the refrigerator to be used for a later date and should have been discarded prior to use by date. She stated the leftover food with danger food temperature between 40 degrees Fahrenheit to 140 degrees Fahrenheit should have been discarded. She further stated she was responsible to ensure the department met requirements for safe food storage and handling and the dietary staff would receive in-services on proper handling, storing, and dating leftover food for compliance.Record review of the facility's policies and procedures for Food Safety, dated 03/30/23, it read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded on the used by date unless otherwise indicated. For food storage, keep off floor.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 12 residents ( Residents #6, #30, #28, #15 #7, #35 and #5) and 5 of 5 staff (CNA J, MA T, LVN AF ,RN W, RN CC ) and 1 of 2 linen closets (Linen Closet B) reviewed for infection control. 1. RN CC failed to wipe the blood pressure cuff between Resident #7, Resident #35 and Resident #5 on 2/24/26.2. MA T failed to wipe the blood pressure cuff between Resident #28 and Resident #15 on 2/24/26.3. LVN AF failed to wear PPE when administering Resident #30's G-Tube medications, who was on EBP, on 2/24/26.4. RN W failed to wear PPE when administering Resident #6's G-Tube medications, who was on EBP, on 2/24/26.5. The facility failed to ensure CNA J cleaned in between and around Resident #4's buttocks and failed to open the labia to clean during incontinent care on 2/26/26.6. The facility failed to ensure Linen Closet B did not contain an unknown staff members black purse and grey zip-up hoodie, on 02/26/2026.These failures could place residents at risk for spread of infection and cross contamination and decrease in quality of life. Findings include:1. During an observation on 02/24/2026 at 7:15 a.m. revealed RN CC performed a blood sugar test and blood pressure checks. RN CC did not wipe the blood pressure cuff in-between uses after checking Resident #7, Resident #35 and Resident #5's blood pressure.During an interview on 02/24/2026 at 11:51 a.m. with RN CC she said she forgot to wipe the blood pressure cuff between residents, she knew better because it was for infection control and the DON had given them a lot of in-services on wiping out BP cuff in-between residents.2. During an observation of medication administration on 02/24/2026 at 8:15 a.m., MA T did not wipe the blood pressure cuff in-between and after checking Resident #28 and Resident #15's blood pressure. During an interview on 02/24/2026 at 9:21 a.m., MA T said she forgot and the DON gave them a lot of in-services on wiping the BP cuff in-between residents .MA T said it could cause cross-contamination if she did not wipe the cuff between residents.3. Record review of Resident #30's face sheet, dated 02/24/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #30 had diagnoses which included: iron deficiency anemias (not having enough healthy red blood cells to carry oxygen to the body's tissues), anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (blood vessels is too high), and heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids), Parkinson's disease is (progressive neuro degenerative disorder, not a condition with a functional use. It involves the death of brain cells that produce dopamine), gastro-esophageal reflux disease without esophagitis (gastric reflux), hemiplegia and hemiparesis (the severe or total paralysis one side of the body) following cerebral infarction (blood flow blocked to part of the tissue of the brain resulting to tissue dying due to a lack of oxygen and nutrients) affecting right dominant side, chronic kidney disease (cannot properly filter waste and extra fluid from your blood, causing toxins to build up) and dialysis (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). essential (primary) hypertension (high blood pressure) heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), hypokalemia (lower than normal potassium level in the bloodstream), dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach)Record review of Resident #30's admission MDS, dated [DATE], reflected the BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment. The resident was totally dependent to bed repositioning and personal hygiene. Resident #30 was incontinent to bladder and bowel . Record review of Resident #30's care plan, dated 12/24/25, reflected Resident #30 had an ADL self-care performance deficit, the goal was resident would improve current level of function through the review date: Resident #30 required total assist with one to two person for bathing/showering, dressing, bed mobility, personal hygiene, toilet use and follow principles of infection control and universal precaution to incontinent care.Observation of medication administration on 2/24/26 at 9:40AM by LVN AF revealed LVN AF gave Lacosamide 100 mg 1 tablet after crushing it and Polyethylene Glycol 3350 (17 gm) dissolved in water and administered via Resident #30's G-Tube. Resident #30's door had EPB posted. LVN AF did not wear a gown or gloves.Interview on 2/26/26 at 10:15AM with LVN AF said for not using EBP while administering medication to Resident #30, she did not know she had to put on gown because she has been doing traveling nurse and had not been doing that before and orientation when the surveyor brought it to her attention that she did not follow EBP protocols.4. Record review of Resident #6's face sheet, dated 2/24/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #6 had diagnoses which included: hyperlipidemia (high lipid/fat in the blood), anemia (low blood count), diabetes mellitus ( high glucose in the blood), essential (primary) hypertension (high blood pressure), heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs) and Parkinson's disease without dyskinesia, without mention of fluctuations, contracture, left hand, dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), glaucoma (high fluid pressure inside the eye) and protein-calorie malnutrition.Record review of Resident #6's quarterly MDS assessment, dated 1/30/26, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required total assistance from staff with ADL's care.Record review of Resident #6's physician order dated 2/1/2024 revealed in part . Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa) Give 1 tablet via PEG -Tube three times a day related to Parkinson's Disease without Dyskinesia, without Mention of Fluctuations.Record review of Resident #6's physician order for February 2026 revealed in part . Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa) Give 1 tablet via PEG-Tube three times a day.During an observation on 2/24/26 at 12:50 p.m. revealed RN W punched 1 tablet of Carbidopa-Levodopa Oral Tablet 10-100 MG into a medication cup, crushed it and diluted with 15mls of water, dissolved and administered via GT. Resident #6's door had an EBP sign posted. RN W did wear PPE, including gown and gloves, before administering G Tube medication.Interview with RN W on 2/24/26 at 1:15 p.m. revealed RN W said she forgot to wear PPE during G-Tube medication administration, and she knew not wearing PPE could cause infection to the resident and herself.5. Record review of Resident #4's face sheet, dated 2/24/2026, reflected the resident was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included neuralgia and neuritis ( intense, often unbearable, stabbing or burning pain that follows the pathway of a damage or irritated nerve), nausea with vomiting, legal blindness, (as defined in USA), hydrocephalus (water in area of brain), other recurrent depressive disorders, polyneuropathy (a condition where multiple nerves outside the brain and spinal cord are damaged simultaneously, causing numbness, tingling or burning pain typically starting in the feet and hands), urinary tract infection and stage 3 sacral pressure ulcer .Record review of Resident #4's quarterly MDS, dated [DATE], reflected the BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. The resident was totally dependent on bed repositioning and personal hygiene. Resident #4 was incontinent to bladder and bowel.Record review of Resident #4's care plan, dated 12/24/25, reflected [Resident #4] has an ADL self-care performance deficit, the goal was resident will improve current level of function in through the review date: [Resident #4] required total assist with one to two persons for bathing/showering, dressing, bed mobility, eating, personal hygiene/oral. Toilet use and follow principles of infection control and universal precautions to incontinent care.Record review of Resident #4's MAR reflected she was on antibiotics Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl on 2/19/26 for 5 days urinary tract infection.)Observation of incontinent care performed by CNA J on 2/26/26 at 10:35 AM and assisted by LVN TN XX revealed Resident #4 was lying in bed on her back with a foam wedge. CNA J donned (put on) clean gloves, unfasten the resident's brief which was soaked with urine and feces, used the wet wipes cleaned in-between the buttocks, but did not clean around the buttocks. CNA J placed a brief under Resident #4's buttocks and she then proceeded to clean the perineal area, cleaned the right groin, and she did not open the resident's labia to clean, change gloves she fastened the clean brief then doffed (take off) her dirty gloves.Interview with CNA J on 2/26/26 at 10:36 AM, she said she had been working 2 years, then on PRN she worked 6:00 AM -2:00 PM. She said it was the first time performing incontinent care since came to work on 2/26/26, because she was waiting to change Resident #4's brief when LVN TN XX did her treatment. She stated she did not open the resident's labia to clean and not cleaning around resident buttocks. CNA J said she had in-services bi-weekly about incontinent care.Interview with LVN TN XX on 2/26/26 at 10:58 AM, revealed what she thought CNA J did not do when performing incontinent care. LVN TN XX said CNA J did not open the labia to clean and she did not clean around the buttocks. LVN TN XX stated residents were supposed to be changed every 2 hours and CNA J would need in-services.Interview with CNA J on 2/26/26 at 11:12 AM, she said she thought she messed up. She stated she did not open the resident's labia and didn't clean around the resident buttocks. CNA J said not cleaning Resident #4 well could cause urinary tract infection.Interview with the regional DON on 2/26/26 at 5:10 PM, he said CNA's were to perform incontinent care every 2 hours and as needed. The Regional DON said, he monitored CNAs randomly for incontinent care/infection control .6. Observation and interview with the HKS on 2/26/2026 at 10:59 AM, in Linen Closet B, there were personal staff items which included a small black purse and grey zip-up hoodie hanging on faucet handles along the back wall. There were clean towels, bed sheets and blankets in the closet stacked on the shelves next to the personal items. HKS said those belonged to facility staff, but he did not know whose they were. HKS said staff knew not to put their personal items in the clean closet and they had their own place to store them and this could have caused cross-contamination. HKS took the bag and hoodie and went down the hall .Interview with the Administrator on 2/26/2026 at 4:35 PM, she said staff personal items should be in staff break rooms and not in the clean linen closet due to cross-contamination . Record review of the facility's, undated, Skilled check list, titled Catheter Care-Skill, read in part, 10. With non-dominant hand: Female: Gently retract labia to fully expose urethral meatus and catheter insertion site. Maintain position of hand throughout.14. Using a clean washcloth, clean catheter tubing using one cloth per stroke, in a circular motion. Clean from the most proximal (Closest to the body) to the most distal (Farthest for the body). Continue cleaning in this manner until tubing is closed.Record review of the facility's policy on Infection Control, undated, read in part, Gloving: Gloves are worn for three important reasons: 1. To provide protective barrier and prevent gross contamination of the hands whentouching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The wearing of gloves in specified circumstances will reduce the risk of exposures to blood-borne pathogens and is mandatory for all employees. 2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes and nonintact skin. 3. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washed after gloves are removed. 4. Masks, respiratory protection, eye protection, face shields 1. A mask that covers both the nose and mouth and goggles or a face shield are worn by personnel during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions to provide protection of the mucous membranes of the eyes, nose, and mouth from contact transmission of pathogens. The wearing of masks, eye protection, and face shields in specified circumstances is mandatory. 2. A surgical mask is generally worn by personnel to provide protection against spread of infectious large-particle droplets that are transmitted by close contact and generally travel only short distances (up to 3 feet) from infected residents who are coughing and sneezing. 5. Gowns and protective apparel 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures.2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environment. 6. Resident care equipment and articles.3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. 7. Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms. Hygienic and common-sense storage and processing of clean and soiled linen is recommended.

Based on observation, record review and interviews, the facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 2 of 18 residents (Residents #57 and CR#75) reviewed for care plans. The facility did not review and update Resident #57's care plan when he had an 18.8 pounds weight loss.The facility did not review and update CR #75's care plan when she had behaviors of refusing care, throwing things on the floor, hitting walls and throwing stuff on the floor. These failures could place residents with weight loss and behavior issues from getting the care and services that could improve their quality of life. Resident #57Record review of Resident #57's clinical records dated 2/25/2026 revealed he was a 73-year male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (is brain disorder that affects memory, thinking and behavior), and dysphagia (swallowing difficulties),. Record review of Resident #57's admission MDS dated [DATE] revealed for Section C, 500 revealed the resident had a BIMS score of 11 indicating he had cognitive issues. For Section K200: Weight and Height he was coded 65 inches for height and weight was 142 pounds. Record review of facility weight record revealed the following weights:1/9/2026 his weight was 142 pounds2/2/2026 his weight was 123.2 pounds.This resulted in a weight loss of 18.8 pounds weight loss. Record review revealed the care plan was last reviewed on 12/13/2025. Further record review revealed the care plan was not revised to address Resident #57's weight loss of 18.2 pounds on 2/2/2026. CR#75 Record review of CR#75's clinical records dated 2/24/2026 revealed she was a 76-year female who was admitted to the facility on [DATE]. Her diagnoses included Non-Alzheimer's dementia (memory loss), and altered mental status (a change in mental function). Record review of CR#75 admission MDS dated [DATE] Section C, 500 revealed the resident had a BIMS score of 10 indicating she was cognitively aware. For Section E200: she was coded as having no behavior. Record review of the nurse's progress notes revealed the following:1/06/2026: CR#75 refused staff assistance, refused to eat stating she was not hungry and did not like the food.1/10/2026 at 1:38 am CR#75 got out of bed screaming and yelling.1/10/2026 at 1:34 pm CR#75 acting very agitated cursing staff, kicking walls and throwing things on floor.1/11/2026 CR#75 refused care and breathing treatment. Record review of CR#75 Care Plan initiated 1/06/2026 revealed the care plan was not review and revised to address the resident's behavior of refusing care, cursing at staff, screaming and yelling and pushing her walker in the wall. In an interview on 2/26/2026 at 3:36pm with MDS Coordinator AK said she was new to the facility and she was not the one who did the MDS. She said dietary was responsible to review the MDS. She said Resident #57's care plan should be revised to address his weight loss. She said, when there were changes in residents' condition the care plan should be revised to address the changes. In an interview on 2/26/2026 at 4:33pm the Regional Nurse said it was the MDS Coordinator's duty to assess the residents and if there were any issues they should be addressed on the care plan. He said care plans should be updated when there are changes in residents' condition. He said the appropriate intervention should be placed to address residents' needs. She said the behaviors for Resident #75 should be addressed in her care plan. Record review of the undated Comprehensive Care Planning read in part.The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings.The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. Comprehensive Care PlansA comprehensive care plan will be- Developed within 7 days after completion of the comprehensive assessment. Prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to--o The attending physician.o A registered nurse with responsibility for the resident.o A nurse aide with responsibility for the resident.o A member of food and nutrition services staff.o To the extent practicable, the participation of the resident and the resident's representative(s). An explanation will be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.O or Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team (IDT) meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the facility. In instances where an IDT member participates in care plan development, review or revision via written communication, the written communication in the medical record will reflect involvement of the resident and resident representative, if applicable, and other members of the IDT, as appropriate.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain, grooming, and personal hygiene for 1 of 3 residents (Resident #4) reviewed for ADL care. The facility failed to ensure CNA J cleaned Resident #4 in a timely manner on 2/26/26. This failure could place residents at risk for pain, infection and hospitalization.Record review of Resident #4's face sheet, dated 2/24/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses of urinary tract infection and stage 3 sacral pressure ulcer. Record review of Resident #4's quarterly MDS, dated [DATE], reflected the BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 was incontinent to bladder and bowel. Record review of Resident's #4's care plan, dated 12/24/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Record review of Resident #4's weekly skin assessment on 2/26/26, reflected pressure wound was not deteriorating and wound doctor was evaluating the wound. Record review of nurse's progress reflected in-facility pressure ulcer wound care by the 2/18/26 by wound doctor was STAGE 3 PRESSURE WOUND OF THE LEFT HIP FULL THICKNESS and physician order was DRESSING TREATMENT PLAN Primary Dressing(s) Santyl apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Alginate calcium apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Observation of incontinent care performed by CNA J and pressure ulcer treatment on 2/26/26 at 10:35 AM performed by LVN TN XX revealed Resident #4 was lying in bed on her back with foam wedge. CNA J donned (put on) cleaned gloves unfasten brief soaked with urine and feces, the was no dressing to the left hip pressure ulcer, there was small brownish drainage on the soaked brief. Interview with CNA J on 2/26/26 at 10:36 AM she said she has been working 2 years, then on PRN she works 6:00 AM -2:00 PM. CNA J said she was not aware that the dressing was not in place, CNA J said would have informed LVN TN XX. She said it was the first time performing incontinent care since came to work on 2/26/26, because she was waiting to change Resident #4's brief when the LVN TN XX does her treatment. She said Residents were supposed to be changed every 2 hours and as needed. CNA J said she was in-serviced for incontinent care and skilled check, checking on resident every 2 hours for incontinent needs. CNA J knew if dressing was in place to the pressure ulcer, it could lead to wound not healing well and infection. Interview with LVN TN XX on 2/26/26 at 10:58 AM, LVN TN XX said she was not aware that the old dressing on Resident #4 came off and would have changed the dressing earlier. LVN TNXX said the CNAs were supposed to inform the charge nurse if old dressing to pressure ulcer fall off during incontinent care to prevent infection getting on the wound. Residents were supposed to be changed every 2 hours and report any skin condition to the nurses and CNA J would need in-services. Interview with the Regional DON on 2/26/26 at 5:10 PM, he said CNAs were to perform incontinent care every 2 hours and as needed. Regional DON said, he did monitor CNAs randomly for incontinent care/infection control. Record review of the facility's policy on Nursing: Personal Care Perineal Care, revised 04/25/22, reflected: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 3 residents (Residents #4) reviewed for incontinent care, in that: CNA J did not open Resident #4's labia to clean during incontinent care on 2/26/26. This failure could place residents at-risk for infection due to improper care practices. Record review of Resident #4's face sheet, dated 2/24/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses of urinary tract infection and stage 3 sacral pressure ulcer. Record review of Resident #4's quarterly MDS, dated [DATE], reflected the BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #4 was incontinent to bladder and bowel. Record review of Resident #4's care plan dated 12/24/25 reflected Resident #4 has an ADL self-care performance deficit, the goal was resident will improve current level of function in through the review date: Resident #4 required total assist with one to two persons for bathing/showering, dressing, bed mobility, eating, personal hygiene/oral. Toilet use and follow principles of infection control and universal precautions to incontinent care. Record review of Resident #4's MAR reflected she was on antibiotics: Ciprofloxacin HCl Oral Tablet 500 MG (Ciprofloxacin HCl on 2/19/26 for 5 days urinary tract infection. Observation of incontinent care performed by CNA J on 2/26/26 at 10:35 AM and was assisted by TN XX revealed Resident #4 was lying in bed on her back with foam wedge. CNA J donned (put on) clean gloves and unfastened Resident #4's brief which was soaked with urine and feces, using wet wipes cleaned in-between the buttocks and did not clean around the buttocks. Then CNA J placed a brief under Resident #4's buttocks and she then proceeded to clean the perineal area, cleaned the right groin, and she did not open the resident's labia to clean, change gloves she fastened the clean brief then doffed (take off) her dirty gloves. Interview with CAN J on 2/26/26 at 10:36 AM she said she has been working 2 years, then on PRN she works 6:00 AM -2:00 PM. She stated she did not open the resident's labia to clean and not cleaning around resident buttocks. CNA J said she had in-services bi-weekly about incontinent care. Interview with TN XX on 2/26/26 at 10:58 AM, TN XX said CNA J did not open the labia to clean and she did not clean around the buttocks She stated CNA J would need in-services. Interview with CNA J on 2/26/26 at 11:12AM She said she thought she did mess up. She stated she did not open the resident's labia and did not clean around the resident's buttocks. CNA said not cleaning Resident #4 well could cause urinary tract infection. Interview with the Regional DON on 2/26/26 at 5:10 PM, he said CNAs were to perform incontinent care every 2 hours and as needed. Regional Nurse said, he did monitor CNAs randomly for incontinent care/infection control. Record review of the Skilled check list, titled Care-Skill, undated, read in part, . 10. With non-dominant hand: Female: Gently retract labia to fully expose urethral meatus and catheter insertion site. Maintain position of hand throughout.14. Using a clean washcloth, clean catheter tubing using one cloth per stroke, in a circular motion. Clean from the most proximal (Closest to the body) to the most distal (Farthest for the body). Continue cleaning in this manner until tubing is clean.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 2 of 3 residents (Resident #30, #6) reviewed for feeding tubes. -The facility staff failed to ensure LVN AF allow medication and feed flow by gravity. Resident #30's medication and feeding was plunge via G tube and LVN AF did not flush GTube with water before and after medication 2/24/26. -The facility staff failed to ensure RN W allow medication and water flow by gravity. Resident #6's medication was plunged into GTube on 2/24/26. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization. Record review of Resident #30's face sheet dated 02/24/26 revealed a [AGE] year-old male was admitted on [DATE] and re-admitted on [DATE]. Resident #30 had a diagnosis of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach). Record review of Resident #30's admission MDS, dated [DATE], reflected the BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #30 was incontinent to bladder and bowel. Record review of Resident #30's care plan dated 12/24/25 reflected Resident #30 has an ADL self-care performance deficit; the goal was resident will improve current level of function through the review date: Record review of Resident #30's Physician's Orders, dated 02/1/26, reflected the following orders: Had NPO (Nothing per oral) only GT: Bolus give 1 can Isosource 1.5 five times a day. Check for residual every shift if > 150cc's, stop feeding and notify MD every shift. Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift. Observation of medication administration on 2/24/26 at 9:40AM by LVN AF, aspirated 58ml of milky fluid and pour it in a cup, then aspirated additional 30 mls milky fluid via G Tube, LVN AF then plunged medication and milky fluid via G Tube to Resident #30's stomach and then aspirated 58 mls in the cup and plunged it via G Tube LVN AF aspirated Lacosamide 100 mg 1 tablet after crushing it and Polyethylene Glycol 3350 (17gm) dissolved in water in 60 mls syringe and plunged via Resident #30's G-Tube. LVN AF did not flush GTube with water before and after medication. Interview on 2/26/26 at 10:15AM with LVN AF about medication and milky residual not given to Resident #30 on 2/24/26, by gravity, she said she feed Resident #30 earlier and was just checking the residual to ensure Resident was not too full. LVN AF did not give any response to why medications and residual was not given by gravity and she did not flush G Tube before and after medication administration. Resident #6 Record review of Resident #6's face sheet dated 2/24/26 revealed an [AGE] year-old female resident that was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #6 had a diagnosis of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach). Record review of Resident #6's quarterly MDS assessment, dated 1/30/26, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required total assistance from staff with ADL's care. Record review of Resident #6's physician order for 2/1/2024 revealed in part . Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa) Give 1 tablet via PEG-Tube three times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS. During an observation on 2/24/26 at 12:50 p.m. revealed RN W punched 1 tablet of Carbidopa-Levodopa Oral Tablet 10-100 MG into a medication cup, crushed it and diluted with 15mls of water and dissolved, RN W then used 60cc syringe aspirated 30 cc of water, she poured in a glass cup and plunged it via GT. RN W then administered medication by plunging it via G Tube. During an interview with RN W on 2/24/26 at 1:15 PM, , RN W said she had hard times with Resident#6's G tube checking for placement and RN W knew not allowing water and medication to flow by gravity could cause aspiration pneumonia, bloating and being too full. RN W said he had medication training upon hire by DON. During an interview on 2/25/26 at 2:50 PM, the Regional Nurse said check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication and water, feeding and medication she be administered by gravity. The Regional Nurse said plunging water, feeding and medication could result in infection, bloating, or discomfort. Record review of the facility provided policy titled Gastrostomy Tube care, undated, reflected the following . Policy Explanation and compliance Guidelines .3. Attach the syringe barrel to the feeding tube and irrigate with 30 mls water to check for the tube patency.5.Allow the feeding to flow by gravity adding more formula before the barrel empties until the entire measured amount is given6. flush with 30-60 ml water to clear the formula

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurses Cart East Wing) reviewed for medication storage. The facility failed to ensure the East Wing nurse medication cart did not contain opened and undated medication. This failure could place residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing. During an observation on [DATE] at 4:44 PM of the nurse medication caret for the East Wing revealed the following opened medications were not dated when they were opened: The following eye drops were open with no date:1. Ciprofloxacin Ophthalmic2. Refresh Tears3. Cipri Dexa [NAME] 0.3-0.1 Interview with RN Z on [DATE] at 4:44 PM revealed she was not aware of the following eye drops that were opened and not dated. She stated the medication was good for 30 days for effectiveness. RN Z said she checked her medication cart whenever she administered her medications. During an interview on [DATE] at 2:38 p.m., the Regional Nurse said eye drops opened should have an open date. The Regional Nurse said the medicines would not be effective for the treatment after 30 days. Record review of the facility's policy, revised February 2023, Storage of drugs and Biologicals: Medication Labeling reflected: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 1. The medication label includes, at a minimum .expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions.

Based on interview and record review the facility failed to develop policies and procedures to ensure the resident's medical record included documentation that indicated, at minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 1 of 5 residents (Resident #8) reviewed for immunizations.The facility failed to ensure Resident #8 had record of receiving education or being offered the pneumococcal vaccine. This failure could cause residents to be vulnerable to preventable illnesses. Record review of Resident #8's face sheet, dated 02/26/2026, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included chronic congestive heart failure, unspecified dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), cognitive communication deficit, hyperlipidemia (high cholesterol) and chronic obstructive pulmonary disease (blockages in lungs creating difficulty breathing).Record review of Resident #8's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated high cognitive intactness related to thinking and memory. Section I - Active Diagnoses documented her pneumococcal vaccination was not up to date and it was not received due to not being offered. Record review of Resident #8's immunization page in her medical records, reflected she did not have any record of current or prior pneumococcal vaccines since admission. Record review of Resident #8's progress notes, reflected there was no record of education or vaccination since admission. Resident #8 did not have any infection requiring antibiotics. Interview with Resident #8 on 2/25/2026 at 10:30 AM, revealed she appeared well-groomed and in a pleasant mood and no apparent distress. Attempted interview with Resident #8's RP on 2/26/2026 at 3:30 PM was unsuccessful, a voicemail was left and no returned communication as of exit.Interview with the Regional Nurse on 2/26/2026 at 6:45 PM, he said he could not locate Resident #8's pneumococcal vaccination records. He stated Resident #8's immunizations should have been in the corresponding section in her medical record, which included the education and uploaded documentation which indicated she either received or refused the pneumococcal vaccine. This vaccine would have been offered upon admission and documented by either the charge nurse or the ADON at the time. A negative outcome of not receiving the vaccine would be Resident #8 could have gotten ill from not being vaccinated.Request from the Administrator for Resident #8's education and documentation of pneumococcal vaccine on 2/26/2026 at 5:29pm was sent by email. No documents were supplied as of exit. Record review of the facility's, undated, policy on Influenzas and Pneumococcal Vaccine, read in part, It is the policy of this company that all residents will be offered the pneumonia immunization unless the immunization is contraindicated or the resident has already been immunized.The facility will maintain documentation of pneumonia vaccinations or refusals of the pneumonia immunization in the Point Click Care clinical record and will include:o That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumonia immunization; [NAME] That the resident either received the pneumonia immunization or did not receive the pneumonia immunization due to medical contraindication or refusal.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for accidents and supervision. The facility failed to ensure that CNA B provided the necessary care and supervision to Resident #1 by ensuring CNA B did not sleep when providing 1:1 supervision to Resident #1 who has a history of falls with injury, including a recent subdural hematoma, CT scan done on 9/12/2025 showed the worsening as indicative by the findings as it noted significant interval change developed of hemorrhage since prior examination, there is a mixed density left subdural hematoma overlying the left cerebral convexity measuring up to 1.0 cm in thickness increased in size compared to 8/21/25 when measure 0.7 cm.The noncompliance was identified as Past Non-Compliance. The PNC IJ began on 09/12/2025 and ended on 09/12/2025. The facility corrected the noncompliance before the survey began. This failure could place dependent residents at risk for falls to experiencing serious injury, pain and hospitalization. Record review of Resident #1's face sheet dated 09/17/2025 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included intracranial injury with loss of consciousness (a brain injury that causes a person to lose awareness of their surroundings and body), traumatic subdural hemorrhage with loss of consciousness status unknown ( a serious medical condition where a collection of blood forms between the brain and the inner layer of the skull (dura mater) causing pressure on the brain and loss of conscious), epidural hemorrhage with loss of consciousness status unknown (bleeding between the skull and outer lining of the brain followed by loss of consciousness), personal history of other disease of the respiratory system (condition that affect the lungs and airways making it difficult to breath), initial encounter, contusion and laceration of left cerebrum with loss of conscious of 30 minutes or less (severe traumatic brain injury involving a physical tear of the tissue in the left largest part of the brain associated with temporary or prolong loss of awareness), acute cystitis with hematuria (inflammation of the bladder lining caused by bacteria and blood in the urine), pain (physical discomfort ranging from mild to severe), lack of coordination (pattern walking or moving on foot), hypertension (high blood pressure), hyponatremia, (low levels of sodium in the blood), seizure (uncontrolled jerking, loss of consciousness and blank stares), moderate protein calorie malnutrition (a condition that occurs when a person does not consume enough protein and calories to meet their body needs), dysphagia (difficulty swallowing), hypo-osmolality (a condition where the concentration of solutes such as sodium, potassium and glucose is lower than normal), atelectasis (complete collapse of the lung or a section of a lung), paralytic gait (abnormal walk resulting from paralysis or weakness of the leg), muscle weakness (decrease strength in the muscle) and other symbolic dysfunction (language impairments caused by an underlying medical condition). Record review of Resident #1's admission MDS dated [DATE] revealed the following: C1000: Cognitive Skills for Decision Making Resident #1 was coded as severely impaired for cognition indicating he was cognitively unaware. Section G0130: Functional Abilities For eating Resident#1 was coded as needing supervision. For oral hygiene, toileting hygiene, shower/bathe, upper/lower body dressing, putting on and taking off shoes and personal hygiene he was coded as needing substantial or maximal assistance. Section J: Health Condition J- 1700 coded Resident #1 as having falls in the last 2-6 months. J- 1800 coded Resident #1 as having 1 fall since admission. J- 1900 coded Resident #1 as having no injuries from the fall at the facility. J- 2100 coded Resident #1 as having recent major surgery. J- 2688 coded Resident #1 as having major neurological surgery. Record review of Resident #1's care plan dated 9/1/2025 revealed: Cognition Focus: Resident has impaired cognition or thought process Goal: To improve cognition level through the next review date. Intervention: Administered medications as ordered. Communicating with residents Use resident preferred name, identify self at each interaction. Face resident when speaking and making eye contact. Activities of Daily Living Focus:The resident has ADL care performance deficit.Goal:The resident will maintain or improve current level of functioning in bed mobility, transfer, dressing, eating, toilet use and personal hygiene.Intervention:For bed mobility and transfer the resident need 1 staff for assistance. For eating he needs supervision. For personal hygiene, bathing/showering and dressing he needs 1 staff assistance. Praise resident for all efforts. Focus : Falls Resident #1 had actual fall and remains at risk for injury d/t falls r/t cognitive impairment and noncompliance with callingfor assistance. Resident risk for injury will be minimized through IDT intervention through next review dateGoal Anticipate and meet the resident's needs.Intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as therapy Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in W/C. fall mats bilateral Keep furniture in a locked position. Keep needed items, water, etc., in reach. Pt evaluate and treat as ordered or PRN. Resident #1 has actual falls and remains at risk of injury due to falls, cognitive impairment and non-compliance of calling for assistancePer negotiation related to fall risk arrangement bed removed and mattress placed on the floor.Resident wears helmet every shift while up in wheelchair as tolerated.Revision of information on past falls in an attempt to determine causes of falls. Record review of Resident 1's hospital discharge report dated 8/28/2025 revealed diagnoses including traumatic brain injury (brain dysfunction caused by an outside force usually a violent blow to the head) temporal hemorrhagic contusion (brain bruise with bleeding in the temporal lobe of the brain). The brain has a small left temporal contusion (bruise on the left side of the brain's temporal lobe, cause by the brain hitting the inside of the [NAME] during a traumatic head injury), and left laceration and hematoma to the frontal scalp (tear in the skin on the left side and hematoma is a collection of blood that pools under the skin to left right frontal scalp). Stubble areas (areas of a man's face typically on the jaw line) slightly decreased attenuation peripherally in the left temporal region, represent small hemorrhagic contusion ((a type of brain injury that occurs when blood vessels in the brain are damaged leading to bleeding in the brain). No other intracranial abnormalities. No subdural (a pool of blood between the brain and its outer covering) or epidural hematoma (bleeding between the skull and outer lining of the brain followed by loss of consciousness), or vascular hemorrhage (the escape of blood from the circulatory system).Repeat CTB1. Significant interval change developed of hemorrhage since prior examination.2. 5.6 x3.0x4.o hematoma (collection of blood that pools outside the blood vessels) has developed in the left lobe.3. Left cerebral convexity subdural hematoma (collection of blood on the surface of the left side of the brain) 8mmin maximal thickness had developed and they are thin subdural hematomas along the tentorium falx.4. Narrowing left lateral ventricle due to extrinsic compression.5. 5mm of right ward subfalcine herniation (a condition where part of the brain tissue protrudes (herniates) under the faix cerebri, a sickle-shaped fold of dura mater (protective covering of the brain) that separates the two cerebral hemispheres). Record review of Resident #1 nurses' notes written by LVN B dated 9/12/2025 at 03:56 am revealed: At 03:56 am the Sitter came to the nursing station stating that the resident (Resident #1) wanted to use the restroom and when she was about to transfer him from bed to the wheelchair, instead of sitting on the chair, he gently sat on the floor, the nurse when went to the room on getting there resident was observed sitting on the floor, no injury noted.At 4:12 am Resident #1's BP-132/79. T-97.8. P -68. R-18. BS-N/A. Resident had a fall. Location: Resident Room. Fall information: Assisted, Missed seat of chair, Cognition / Behavior at Time of Event: Cognitive Impairment, . Resident wanted to be transferred from bed to wheelchair, but instead of sitting in his wheelchair. he gently sat on the floormat. no injury no pain. Initial Treatment/New Orders: N/A Resident Statement: It was witness by his sitter Name of MD/NP notified:At 6:30am MD/NP, RP notified: Interventions in place prior to fall: 1 on 1 supervision, Interventions initiated in response to fall: 1:1 supervision.At 8:54am Head to toe assessment done by DON for Resident #1, no apparent injury noted. Vital signs 118/74 84 18 97.6 97% RA. Resident transfer to the hospital for post fall via EMS transportation. Record review of the facility investigation report dated 9/12/2025 revealed at 09:43am nurse's notes documented Resident #1 was transferred to a hospital on 9/12/2025 related to Post fall. This is intended to serve as notice of an emergency transfer. This notice was provided to Resident Representative. Record review of the hospital report dated 9/12/2025 at 8:52 am from Emergency Medicine revealed the following: Report from the facility revealed that Resident #1 got up and fell, hit his head LOC/C spine tenderness. Hx of Craniotomy- has a sitter at the facility.Progress notes dated 9/9/2025-9/12/2025The resident presents to the neurosurgery clinic for evaluation TS/P left decompressive hemicraniectomy for subdural/epidural hematoma (an emergency procedure to remove a blood clot and relieve dangerous pressure on the brain) evaluation. The patient has been in a nursing and rehab facility and has been progressing well. The caregiver at the facility said he was still very spontaneous, trying to get up at all times and he requires 1:1 monitoring. He was able to verbalize better than he was on admit.Resident readmitted back to facility from hospital. CT brain scan done at the hospital stated there is a mixed density left subdural hematoma overly the left cerebral convexity measuring up to 1.0cm. Resident continues 1:1 sitter, fall and safety precaution maintained. Bed in lowest position and call light within reach. RP aware of resident arrival to facility. Record review of the CT scan of the Head without contrast clinical indication done on 9/12/2025:Brain:There is a mixed density left subdural hematoma overlying the left cerebral convexity measuring up to 1.0 cm in thickness increased in size compare to 8/21/25 when measure 0.7 cm. Previously noted pneumocephalus has resolved.There are scattered areas of hypoattenuation within the intracranial white matter. While nonspecific, this is most suggestive of mild chronic microvascular ischemic disease. Redemonstrated encephalomalacia and gliosis in the left anterior temporal lobe. No definite new intraparenchymal hemorrhage. No midline shift. Postsurgical change from a left cerebral craniectomy and or no fracture status post-surgical fixation involving portion of the left sphenoid bone. Observation on 9/16/2025 at 7:20am revealed Resident #1 was in bed, he was clean and groomed with no offensive odor. No visible marks, bruises, redness or swelling noted. Resident #1's bed was noted to be in a low position and floor mat on both sides of the bed. A sitter was noted to be in the room. The resident was alert but confused. The resident was noted to be very agitated trying to get up off the bed and turning in all directions on the bed. In an interview on 9/16/2025 at 7:30 am with the CNA C she said she was the sitter, and it was her first time sitting with Resident #1. She said the resident was always trying to get up. She said the night sitter told her he gets really agitated and will try to get up. An attempt was made to interview the Resident#1 on 9/16/2025 at 7:35 a.m. revealed the resident to answer simple questions. He answered no when he was asked if he was in pain and yes when asked if he had fallen. The resident was unable to explain what he was doing when he fell. In an interview on 9/16/2025 at 7:45 am the Administrator said the resident was a 1:1 due to his unsteady gait, agitation and trying to get up all the time. She said along with the DON they decided to have him on 1:1 supervision because of the head injury he had from a fall prior to admission to the facility. She said they did not want him to fall and reopen the wound and that was why they initiated the 1:1 supervision. She said the resident had a fall on 9/12/2025 and they assessed him, and the family was called. She said the family later called back after viewing their video stating the resident did not fall out of his chair, they told them he fell face down on the floor and the CNA was sleeping. She said they immediately reassessed the resident and he was sent to the hospital for evaluation as this was now an unwitnessed fall. She said on assessment the resident had no visible injuries. She said he was evaluated at the hospital and the resident was sent back from the hospital to the facility the same day with no new orders. She said the CNA was suspended pending investigation and will be terminated based on company policy. In an interview on 9/16/2025 at 11:05 am with RN A she said she worked with Resident #1, and he was alert but does not follow command. She said he was nonverbal and would point to the restroom. She said he will get up and gets very agitated at times turning from side to side on his bed and will attempt to get out of bed. She said he has unsteady gait and will fall. She said he has a 1:1 sitter who was provided by the facility. In an interview on 9/16/2025 at 3:15pm with CNA E she said they have in-service training every month. She said she never worked with Resident #1, but she heard of him, and that he has a 1:1 sitter. She said she was in-in-service on abuse, neglect, monitoring 1:1 and falls. Staff said 1:1 means you must always have your eyes on the resident. In an interview on 9/16/2025 at 3:33pm with LVN G she said she was the nurse for Resident #1. She said she assisted the Sitter with taking him to the bathroom at times. She said the resident can get very agitated at times and try to get out of bed. She said he was 1:1 supervision and had to always be in eyesight. She said sometimes he was difficult to redirect. In an interview on 9/16/2025 at 3:45pm with CNA F she said she worked with Resident #1 the first day he was admitted . She said he was very restless and could feed himself. She said they were in-serviced on abuse/neglect, call lights, customer service, mechanical lift training, 1:1 training and fall prevention. Staff were able to verbalize understanding of in-services. In an interview on 9/16/2025 at 5:00pm the DON said Resident#1's 1:1 supervision was initiated by the facility, because of his agitation, unsteady gait and the resident trying to get up all the time. She said she was notified on 9/12/2025 by LVN B that the resident had fallen, and the responsible party was notified. She said LVN B told her the CNA that was providing 1:1 supervision to Resident #1 told her she was taking the resident to the bathroom, and he sat on the floor. She said, when the RP was notified, the RP said she was going to look at her camera. After the family reviewed the video, they called the facility and told them, the resident did not fall out of the chair, he was standing and fell on his face to the floor. She said when she heard the report she immediately went and reassessed the resident. She said on assessment of Resident #1 she did not see any marks, bruises, redness or swelling on the resident's face or body. She said the resident was sent to the hospital via 911 for evaluation due to a previous fall that resulted in head injuries before admission to the facility. She said the resident was reassessed at the hospital; a CT scan was done, and the resident was sent back to the facility with no new injuries or orders. She said after the call from the family she called CNA B and interviewed her. CNA B told her, she dozed off and then she heard a boom, and when she got up, she saw the resident on the floor. DON said they decided to send the resident to the hospital for an evaluation based on what the family said and the report from the CNA that she dozed off as it would be an unwitnessed fall. She said she then requested a copy of the video. She said on viewing the video, she saw the resident staggered but it was difficult to determine if he fell on his face to the floor as that part of the video was missing. She said the CNA was suspended pending investigation and will be terminated for sleeping on the job. In an interview on 9/16/2025 at 9:35pm via telephone with LVN B she said she was working the night shift when the sitter (CNA B) came to her and told her she was transferring Resident #1 to his wheelchair to take him to the restroom and the resident sat on the floor, and she was asking her to help put him back in his chair. She said she went to the room to assist the sitter to get the resident off the floor back in his chair. She said when she got to the room the resident was sitting on the floor. She said she assessed the resident and there was no swellings, bruises or redness on his body/face and the resident did not complain of any pain. She said she checked his vitals, and they were okay. She said the RP, MD/NP and DON were notified. She said the resident was 1:1 with a staff, he was on a low bed with fall mats on both sides of the bed. She said she also initiated neuro checks. She said she was not aware that Resident #1 had fallen face down to the floor, that was why he was not sent to the hospital immediately. She said the CNA was suspended pending investigation. In a telephone interview on 9/17/2025 at 8:45 am with CNA B, she said she was the person who was doing 1:1 supervision with Resident #1 when he fell. She said she was unaware that the resident was up when he fell, she said he fell by the closet door. Further interview with at CNA B revealed she was sitting within arm's length from Resident #1's bed. CNA B said she could not prevent the resident from falling because she dozed off and then she heard boom, and the resident was on the floor. She said she called the nurse and asked her to assist her in getting the resident off the floor. She said she did not tell the nurse the truth. She said the resident did not have any swelling, marks or bruises to his body/face. Interview on 9/17/2025 at 2:30pm with CNA D she said she worked with Resident #1, and she gave him a shower. She said he did not complain of any pain. She said she was in-serviced on abuse, neglect, falls and infection control. She said if a resident was at risk at falling, she would ensure the bed was in the lowest position with fall mats on both sides and check him at least every two hours or as needed. She said they were recently in-serviced on abuse/neglect, fall prevention and 1:1 monitoring. The staff demonstrated understanding of training. Interview on 9/17/2025 at 2:45pm with CNA L she said she worked with Resident #1, and he can get restless at times. She said he did not complain of any pain. She said she was in-serviced on abuse, neglect, falls and infection control. She said if a resident was a fall risk, the bed should be in the lowest position with fall mats and staff should check him at least every two hours or as needed. She said if the resident wanted to use the bathroom he would get up and point to the bathroom. She said they were recently in-serviced on abuse/neglect, fall prevention, infection control and 1:1 monitoring. Interview on 10/01/2025 at 3:07 pm the DON said 1:1 monitoring means to always lay eyes on the individual, the staff should be within arm's reach of the individual. She said they did in-services with everyone on what 1:1 monitoring means, no sleeping on the job. She said the CNA who was sitting with the resident at the time of the fall was suspended and then terminated on 9/17/2025. She said she asked the CNA to tell the truth, and she told her she had dozed off when she heard a boom and when she looked the resident was on the floor. She said moving forward if they have 1:1 supervision for residents they were going to initiate frequent breaks, shorter shifts such as 8 hour shifts especially if the staff was not accustomed to 12-hour shift. They will ensure they have their breaks to prevent fatigue. She said the resident was sent out to the hospital because he had a fall with head injuries prior to coming to the facility and the fall was an unwitnessed fall. She said there were no bruises, no facial injuries, trauma or any evidence he fell face to the floor. She said evidence from the video did not show he fell, it showed the resident just staggered but did not show he hit the floor Further interview on 10/01/2025 at 4:37pm with LVN B she said when she went to the room the resident was sitting on the floor. She said he was beside the bed, and the wheelchair was nearby. She said there was no swelling or bruises when she assessed him. She said she initiated neuro checks and called the RP, DON and physician. Further interview on 10/01/2025 at 4:45pm with CNA B she said Resident #1was in a sitting position on the floor near the closet when she heard the sound. She said he was not on his face and there were no visible injuries, and he did not complain of pain. In an interview on 10/02/2025 at 8:37am Doctor F said when there were unwitnessed falls the NP or the doctor should be called. She said Resident #1 was sent to the hospital for evaluation due to a previous intercranial head injury that he sustained prior to admission to the facility. She said there was no concern at the time because there was no bleeding, no laceration or complaining of pain. She said when he returned from the hospital, he was pretty much the same. She said he had underlined confusion before the fall, she said when he went to the hospital he was evaluated, and was sent back from the hospital the same day. She said nothing was different with him and no new orders were given. In an interview on 10/02/2025 at 8:56am NP C said he did not see Resident #1 prior to going to the hospital but he saw Resident #1 after his return. He said he did not complain of head pain, soreness, redness or swelling. He said there was no negative outcome from the fall. He said he was sent to the hospital due to an unwitnessed fall and based on his previous fall prior to admission where he had head injuries he was sent out to ensure he had no brain bleed or any other head injuries. He said he was sent back with no injuries or orders. He said the negative outcome from that fall could be damage to the brain, brain bleed, soreness and pain. An interview on 10/6/2025 at 4:21pm LVN K revealed she has been working at the facility for over a year. She said they did a lot of in-services. The most recent in-services done were falls, transfers, 1:1 monitoring, no sleeping on the job and call lights. She said she was not working the day the resident fell; however, she was aware that the resident fell while he was under a 1:1 supervision watch. She said the resident should be on a low bed with mats to both sides of the bed. She said the resident mattress was now on the floor. In an interview on 10/06/2025 at 4:45pm MA N said she worked at the facility for 19 years. She said they did a lot of in-services and the most recent in-services they did was on abuse/neglect, showers, time clock, fall prevention and 1:1 monitoring. She said she worked with Resident #1 when she was on break to relieve the sitter. She said he has improved a lot. She said when he was on 1:1 he would try to get up and would not sleep. She said 1:1 means you cannot take your eyes off the person, and you cannot sleep. She said Resident #1 was no longer on 1:1 because his mattress was on the floor with side mats, and he moved around a lot. She said he was more alert and oriented now. She said therapy was working with him, pointing at him walking with therapy, using a walker. The staff demonstrated understanding of training. In an interview on 10/06/2025 at 4:55pm CNA P said she had been working at the facility for 2 months: Said she was in-serviced on falls and transfer and abuse neglect and 1:1 monitoring. She said when you are doing 1:1 you cannot sleep. She said Resident 1 was very active and you must always keep an eye on him. She said he gets agitated at times and will try to get up. Staff demonstrated understanding of training. In an interview on 10/06/2025 at 5:10pm CNA G said she worked at the facility for about 8 months. She said she was in-serviced on abuse and neglect, dementia, incontinent care, 1:1 monitoring, Fall prevention, and safety risk. She said she was aware of Resident #1's fall. She said, when you are doing 1:1 you can't leave the resident out of sight; you are not supposed to sleep you must always keep him insight. She said he was no longer on 1:1. She said his mattress was on the floor and he had fall mats on both sides of his mattress. Staff demonstrated understanding of training. Record review of the video on 9/17/2025 revealed clippings where the resident staggered and stumble but did not observed him hitting the ground. The next review were staff members in the room and the resident in his wheelchair. Record reviews of facility in-services revealed CNA B (received written disciplinary warning and 1:1 education) and nursing staff were educated on 9/12/2025 regarding 1:1 monitoring for residents who were at risk of falling. CNA B was also suspended pending investigation. Record review revealed in-service dated 9/12/2025 revealed staff were educated on the following topics by the Administrator and the DON regarding Abuse neglect, fall prevention and 1:1 monitoring which included not sleeping on the job, always have the resident in eyesight, and resident rights. Record review of in-services done on 09/16/2025 Additional services on abuse/neglect and 1:1 monitoring was done on 9/16/2025 with the Administrator and the DON. Record review of the facility's undated Fall policy read in part .Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall. The MDS 3.0 will also assist in determining a resident who is a fall risk. Procedure 1. On admission, the nurse will complete a fall risk assessment for each resident. 2. If the resident is unable to assist in completion of the tool, or if medical records are unavailable, the nurse may obtain the assistance of a family member or legal representative that is familiar with the resident's current functional status.3. Fall Risk AssessmentThe Fall Risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the residents' medical history, social history, and current functional status. Information may be obtained by reviewing current medical records, interview with resident/family, or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.4. Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.5. Interventions will be resident centered.13. In instances where fall risk measures do not prevent a fall, the resident will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. 15. The nurse will complete an event fall nurses note after each fall. Falls resulting in serious injury will be reported to the DON and/or Administrator.16. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required.17. Appropriate education will be provided to all staff members as needed on fall prevention. EnvironmentalEnsure room has adequate lighting (60watts or greater / non-glare bulbs).Be aware of spills / wet floors. Make sure residents have proper eyewear.Remove clutter from floors / hallways.Shoes should fit properly and have non-skid soles, full backs and adequate arch support.Bed height needs to be appropriate height with wheels locked.Follow toilet schedules, utilize hip protectors for those who are at risk.Watch for raised surfaces (i.e. threshold, steps). [NAME] with bright tape or remove if possible. Furniture should not easily tip or slide.Place frequently used items in drawers that do not require the resident to bend or stoop.Beds and chairs should be positioned so that the resident transfers to their stronger side. Position call bells within reach.Respond timely to call bells and resident's request for assistance.Utilize bed low bed if indicated.Resident's room should be tidy and uncluttered with special attention to detail at night.Rehabilitation: Strengthening, Assistive Devices/Footwear, ROM and Gait. Record review of the facility's Adhoc Qapi dated 9/12/2025 revealed:Findings: Certified Nursing Assistant who was 1:1 to prevent fall, fell asleep and the resident got up and fell.1.The resident currently resides at the facility.2. Certified Nursing Assistance was provided one and one education.3. DON provides in-services on 1:1, Abuse neglect, fall prevention, resident rights,4. All training and education will be provided before the next shift. All information was reviewed with the Administrator, DON, ADON, RN and the medical Director during the Adhoc Qapi meeting on 09/12/2025 to review all findings.The noncompliance was identified as Past Non-Compliance. The PNC IJ began on 09/12/2025 and ended on 09/12/2025. The facility corrected the noncompliance before the survey began, no POC required. On 10/06/2025 at 4:10 p.m., the facility's Interim Administrator, and Regional Nurse were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 10/06/2025 at 4:15 p.m.

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's weight was accurately documented on the admission MDS dated [DATE]. This failure could place residents with weight loss or gain at risk by not receiving care and intervention that could meet their weight needs. Record review of Resident #1's face sheet dated 09/17/2025 reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident#1's diagnoses included intracranial injury with loss of consciousness (a brain injury that causes a person to lose awareness of their surrounding and body), traumatic subdural hemorrhage with loss of consciousness status unknown ( a serious medical condition where a collection of blood forms between the brain and the inner layer of the [NAME] (dura mater) causing pressure on the brain and loss of conscious), epidural hemorrhage with loss of consciousness status unknown (bleeding between the skull and outer lining of the brain followed by loss of consciousness), personal history of other disease of the respiratory system (condition that affect the lungs and airways making it difficult to breath), initial encounter, contusion and laceration of left cerebrum with loss of conscious of 30 minutes or less (severe traumatic brain injury involving a physical tear of the tissue in the left largest part of the brain associated with temporary or prolong loss of awareness), acute cystitis with hematuria (inflammation of the bladder lining caused by bacteria and blood in the urine), pain (physical discomfort ranging from mild to severe), lack of coordination (pattern walking or moving on foot), hypertension (high blood pressure), hyponatremia, (low levels of sodium in the blood), seizure (uncontrolled jerking, loss of consciousness and blank stares), moderate protein calorie malnutrition (a condition that occurs when a person does not consume enough protein and calories to meet their body needs), dysphagia (difficulty swallowing), hypo-osmolality (a condition where the concentration of solutes such as sodium, potassium and glucose is lower than normal), atelectasis (complete collapse of the lung or a section of a lung), paralytic gait (abnormal walk resulting from paralysis or weakness of the leg), muscle weakness (muscle weakness (decrease strength in the muscle)and other symbolic dysfunction (language impairments caused by an underlying medical condition). Record review of Resident #1's admission MDS dated [DATE] revealed the following:C1000: Cognitive Skills for Decision MakingResident #1 was coded as severely impaired for cognition indicating he was cognitively unaware.Section K0200 Swallowing and Nutrition. Section K: 200 coded Resident #1 63 inches and weighs 154 pounds.Section K: 300 coded Resident #1 had no weight loss.Section K:310 and 310 coded Resident #1 had no weight gain Record review of Resident #1's care plan dated 9/1/2025 revealed: CognitionFocus: Resident has impaired cognition or thought process Goal: To improve cognition level through the next review date.Intervention: Administered medications as ordered.Communicate with residentUse resident preferred name, identify self at each interaction.Face resident when speaking and make eye contact. NutritionFocus: Resident has a diet order other than Regular and is at risk for unplanned weight loss or gain.Goal: Resident will maintain ideal weight and receive proper nutrition daily x 90 days.Intervention: Determine food preferences and provide within dietary limitations. Encourage meal completion and document amount consumed. Monitor weight per facility protocol. Offer substitute, if resident eats less than 50% or dislikes meal and offer supplement if a resident continues to eat less than 50%. Praise resident for eating well. RD assess per facility protocol. Serve diet and snacks as ordered. ST eval and Tx per Physicians orders as condition warrants. The resident has a pureed diet. Record review of nurse's notes dated 8/29/2025 revealed admission assessment done for weight, it was documented as zero (no documented weight). Record review of Resident #1's weight record done at the facility revealed weight done on 9/9/2025 was 138 pounds. Record review of the hospital discharge notes dated 8/29/2025 revealed the last weight prior to discharge was done 8/26/2025 was 154 pounds. In an interview on 9/16/2025 at 4:00pm the MDS Coordinator said she must have gotten the weight from the hospital records. She said she had to close the MDS for billing purpose, and she just use the hospital weight. In an interview on 9/17/2025 at 1:15pm with LVN G she said she was the nurse who admitted Resident #1. She said Resident #1 was very agitated and she was not able to do his weight. She said she asked the person who does the weight to weigh him in the morning. She said she was not aware that the weight was not done. In an interview on 9/17/2025 at 1:20pm the MDS Coordinator said she should weigh the resident or have one of the staff to weigh him to ensure his weight was correctly documented on the MDS. She said when doing her MDS she usually gets her information from different disciplines. She said she also looked at the nurse's notes and the CNA's documentation before completing their section of the MDS. She said moving forward she will ensure that all documentation on the MDS was accurate. Interview on 09/17/2025 at 2:30pm with the DON she said her expectation of the nurses were to do proper assessments that was to include talking with the CNA's, observe the residents and review nurses progress notes so they can capture all the change of the resident. She said she will be in- servicing the staff. Record review of the MDS policy and procedures dated 2024 read in part.Policy:Residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1.According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4. Care Plan Team Responsibility for Assessment Completion: Coding of Assessment:I All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment.ii. Within 7 days after completing a resident's MDS assessment or tracking record, the facility must encode the MDS data (i.e., enter the information into the facility MDS software).

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 11-12-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the dumpster door was open. In an interview on 11-12-24 at 8:45 am, with the Director of Food and Nutrition, she stated the dumpster door should not be left open when not in use to prevent bugs, flies, rodents getting in the dumpster and from entering facility. She stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors are kept closed when not in use. Interview with the Administrator on 11/15/24 at 2:30 PM revealed that the facility did not have a policy and procedure on disposal of garbage and refuse.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 4 of 8 residents (Resident #45, Resident #175, Resident #9 and Resident #5,) reviewed for privacy, in that: 1. CNA (certified nursing aid) C failed to place Resident #45 Foley catheter bag inside of a privacy bag. 2. CNA L failed to place Resident #175 Foley catheter bag inside of privacy bag. 3. The facility failed to provide privacy curtain between Resident #9 and Resident #5's bed to identify a separation of space and privacy between the two residents. These failures placed residents at risk for embarrassment, at risk of loss of dignity and decrease in quality of life. The findings include: Resident #45: Record review of Resident #45's factsheet dated 10/15/2024 revealed a [AGE] year-old male admitted to the NF on 09/09/2024. Resident #45's diagnoses included the following: chronic kidney disease, functional quadriplegia (to be completely unable to move due to severe disability from another medical condition), heart disease, pressure ulcers (injury to the skin resulting from prolong pressure on the skin) stage 4 to the sacral (base of the spine) and buttock (back of the hip which a person sits). Record review of Resident #45's MDS dated [DATE] reflected that resident had a BIMS score of 10 indicating the resident's cognition was moderately impaired. Further review revealed section H (bladder and bowel) was coded 9, not rated (resident had a catheter for urinary incontinence). Record review of Resident #45's Physician's Orders for the month of September 2024 reflected the following order: - Dated 09/10/2024 Ensure Foley bag is in privacy bag while in bed or w/c. Record review of Resident #45's Comprehensive care Plan dated 09/23/2024 included the following intervention: - Position catheter bag and tubing below level of the bladder and in a privacy bag. Observation on 11/12/2024 at 9:06 a.m. revealed Resident #45 was resting quietly in bed to his left side with eyes closed. Further observation revealed the resident had an indwelling Foley catheter hanging on the right side of bed to gravity. The Resident Foley bag was not inside of a privacy bag. Observation on 11/13/2024 at 9:22 a.m. revealedof Resident #45 resting in bed with his eyes closed. Further observation revealed his Foley catheter bag was not inside of a privacy bag. Interview on 11/13/2024 at 4:15 p.m. CNA C said she was Resident #45's CNA on 11/12/2024 for 6 a.m. - 6 p.m. shift. CNA C said it was her responsibility regarding Foley care to empty the Foley catheter bag and place the bag inside of a privacy bag. CNA C said that was done to provide the resident with privacy as well as dignity. CNA C said she was not aware on 11/12/2024 that Resident #45's Foley catheter bag was not inside of a privacy bag. The CNA C said it was ADON A that told her to place resident Foley bag inside of a privacy bag until 11/12/2024. Resident #175: Record review of Resident #175's face sheet dated 11/15/2024 revealed a [AGE] year-old female admitted to the NF on o3/29/2024. The resident's diagnoses included malignant neoplasm (cancer) of the uterus (female organ located between the bladder and rectum), obstructive and reflux uropathy (when the flow of urine is blocked) and pressure ulcer of the sacral region (near the base of the spine). Record review of Resident #175 quarterly MDS dated [DATE] reflected the BIMS score was 15 indicating that resident cognition was intact. Further review of section H (bladder and bowel) reflected that resident was always incontinent of bladder and bowel. Record review of Resident #175 Comprehensive Care Plan dated 10/05/2024 reflected the resident was being care planned for an indwelling catheter with an intervention that included: place Foley catheter bag inside of privacy bag. Observation on 11/12/2/4 at 10:15 a.m. revealed Resident #175 was awake, resting in bed. Further observation revealed the resident having an indwelling Foley catheter hanging to gravity on the right side of. The Resident's Foley bag was not inside of a privacy bag. Observation on 11/13/24 at 8:12 a.m. revealedof Resident #175 was resting in bed to her left side. Resident Her Foley bag was inside of privacy bag. Interview on 11/13/24 at 4:28 p.m. Resident #175 said she would prefer that her Foley bag be placed inside of privacy bag because she sometimes had family visit her. Resident #175 said she would not like anyone to see her Foley bag. Interview on 11/15/2024 at 7:48 a.m. CNA L said she was Resident #175's CNA on 11/12/2024 on the 6 a.m. - 6 p.m. shift. CNA L said she was not aware that Resident #175 Foley catheter bag was not inside of a privacy bag. CNA L said the importance of concealing a resident's Foley bag inside of a privacy bag was to protect residents' privacy and that it was the resident's right. Interview on 11/13/24 at 4:33 a.m. ADON B said it was the responsibility of the CNAs's and the nurses on the units to make sure that residents who had a Foley catheter that the Foley bag be in a privacy bag to promote dignity on the resident's behalf. ADON B said it was herself as a Unit Manager and ADON to ensure that was being done. Interview on 11/13/24 at 4:38 p.m. with the DON, regarding Foley bags, said every resident that had a Foley, the Foley bag should be inside of a privacy bag. The DON said that was the resident's right and it also provided dignity for the resident. The DON said it was the nurses on the unit, CNAs', including herself to ensure that this was being done. Resident #9 and Resident #5: Record review of Resident #9's face sheet, dated 11/12/2024, reflected resident was a [AGE] year-old female with an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: schizophrenia (a chronic mental disorder that affects how people think, perceive reality, and interact with others), generalized (osteo) arthritis (pain and stiffness in the joints), dementia (loss of cognitive functioning - thinking, remembering, and reasoning), severity, without behavioral disturbance, psychotic disturbance (abnormal thinking), mood disturbance, and anxiety, psychotic disorder with hallucinations due to known physiological condition, multiple sclerosis (autoimmune disease that effects the brain and spinal cord), type 2 diabetes mellitus without complications (abnormal blood sugar levels), paraplegia (a chronic condition that results in the loss of motor or sensory function), major depressive disorder, recurrent, severe with psychotic symptoms, and, other abnormalities of gait and mobility. Record review of Resident # 9's Quarterly MDS assessment, dated 09/02/2024, reflected the resident had a BIMS score of 09, indicating she was mildly cognitively impaired. Resident #9 required maximum assisted at least half of the time with ADLs, and resident was incontinent for bladder and bowel. Record review of Resident #9's care plan, dated 06/30/2023, reflected Focus: had delusions with poor judgment and insight . was verbally and physically aggressive towards staff and others, yelled and cursed at CNAs during .care, made sexual comments to staff and residents. Goal: will remain safe and her concerns will be addressed. Interventions: observe and document behavior as needed. Resident #5: Record review of Resident #5's face sheet, dated 11/15/2024, reflected an [AGE] year-old female with an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: dementia (loss of cognitive functioning - thinking, remembering, and reasoning), severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, atrial fibrillation (irregular heart rate causing fatigue, dizziness and trouble breathing), major depressive disorder, recurrent, severe with psychotic symptoms, anemia in other chronic diseases classified elsewhere low back pain, hypertensive heart disease without heart failure (raise in blood pressure causing strain on the heart), and adjustment disorder. Record review of Resident #5's Quarterly MDS assessment, dated 09/11/2024, reflected that the Resident had a BIMS score of 00, indicating that the resident was unable to complete the interview. Resident #5 required maximum assisted at least more than half of the time with ADLs, oral hygiene, upper body dressing, and personal care. Record review of Resident #5's care plan, dated 10/24/2024, reflected Focus: Resident had an ADL self-care performance deficit relating to Dementia. Resident is a 2-person assist. Dressing: One person. Observation on 11/12/2024 at 09:14 a.m. reflected Resident #9 and Resident #5's room with 2-beds and personal property near both beds with no privacy curtain between the beds. During an interview on 11/12/2024 at 09:14 a.m., Resident #9 she stated that she had a roommate (Resident #5) who she had not gotten alone with because Resident # 5 complained all the time. She stated that there was never a curtain between their two beds and would like to not have to look at Resident #5 when they were both in the room. She stated when staff assisted her and her roommate dressing, they both were in the room. During an interview on 11/12/2024 at 04:20 p.m., the ADM stated and believed that Resident #9's room was a private room and was the reason why no curtain was hung. She stated that it was possible that Resident #9 moved into that room temporarily after a recent room change. She stated that there should have been a curtain hanged between two residents sharing a room to allow privacy. She stated she would assess the room and have a privacy curtain hung between Resident #9 and Resident #5. During an interview on 11/13/2024 08:06 a.m., the ADM stated that both Resident #9 and Resident #5 were moved out of their room because the room was assigned as a private room. She stated that both residents were relocated to different rooms and were no longer roommates. She stated she interviewed both residents the evening of 11/12/2024 and both residents stated that they were friends and had roomed together for 2-years. During an interview on 11/13/2024 at 11:32 a.m., Resident #5 was asked questions regarding her roommate but did not respond. Resident made eye contact smiled and confirmed that she was resident #5. During an interview on 11/14/2024 at 2:21 p.m., RN O stated that she was the nurse for Resident #9 and Resident #5. She stated she had just returned to the facility and worked last in October of 2024. She had not noticed that the resident's had not had a privacy curtain hanging between their beds. She stated the importance of a privacy curtain was for residents to feel ownership to their own space. She stated also during ADL service, the privacy curtain protects a residence privacy. She stated that it was her expectations that all staff including CNAs who became aware of the missing privacy curtain, should follow the chain of command to have the curtain placed. Record review of the facility's policy titled Resident Rights revised dated 11/18/2016. Privacy and confidentiality reflected in part: .The resident has a right to be treated with respect and dignity .The resident has a right to personal privacy . Asked and not received, a facility policy specific to privacy curtains in resident rooms.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. The facility failed to ensure foods were dated as opened/prepared discarded after used by date /time. These failures could place residents at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen refrigerator on 11/12/24 at 8:15 AM revealed the following: 1. An open box of cream cheese dated 10/30/24 with no use date 2. Sliced deli meat in a plastic bag in the refrigerator dated 11/01/24 3. Sliced Swiss Cheese in a plastic bag in the refrigerator dated 11/01/24 4 Shredded Mozzarella cheese in a plastic bag in the refrigerator dated 10/15 5. Shredded Mozzarella cheese in a plastic bag in the refrigerator dated 11/06/24 6. Sliced deli ham in a plastic bag in the refrigerator and no label no date. 7. Canned beets in a plastic container in the refrigerator dated 11/05/24 and a use by date of 11/12/24 8. Beef stew in a plastic container in the refrigerator dated 11/4/24 and a use by date of 11/07/24 In an interview with the Dietary Food Service Manager on 11/12/24 at 8:20 AM, revealed that she was responsible to make sure dietary staff are labeling and dating food that have to be used later. Also, staff had to discard food prior to expiration date or used by date. She stated she or the designee, shall be responsible for checking the refrigerator daily for food items that were expiring, and shall be discarded prior to expiration date. Record review of facility's policies and procedures for Food Safety dated 2012 reflected in part . perishable opened food shall be used with in 7 days or less, to be in compliance to code 2 with the Texas Food Establishment rules.

Based on interview and record review the facility failed to report the results of all investigations to the State Survey Agency, within 5 working days of the incident for an allegation of abuse to report for 1 of 4 residents (Resident #61) reviewed for abuse/neglect in that: -Resident #61 had an incident with an allegation of abuse on 09/3/2024. The facility did not submit the final 3613 facility investigation report to the State Agency within 5 working days. This failure could place residents at risk of having allegations of abuse, neglect, exploitation not being investigated or reported to the State agency. Findings Include: Record review of the admission record dated October 17, 2024. revealed that Resident #61 was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis after cerebral infarction (related conditions that cause weakness or paralysis on one side of the body) and need for assistance with personal care (a physical, cognitive, or behavioral limitation that makes it difficult for an individual to perform activities of daily living or instrumental activities of daily living (IADLs). ADLs The ADL's included tasks like bathing, eating, dressing, and using the toilet, while IADL'ss include tasks like cleaning, preparing meals, and taking medication. ). Record review of Resident #61's Admission MDS assessment dated [DATE] reflected a BIMS (brief interview for mental status) score of 8 out of 15 indicating he had moderate cognitive impairment. He had upper and lower extremity impairment on one side. Resident #61 required substantial to maximal assistance with bathing/showering, toileting, lower body dressing, putting on and removing footwear. Record review of Resident #61's care plan revealed the following: The resident has LEFT Hemiplegia/Hemiparesis r/t STROKE.LEFT HAND CONTRACTURE Date Initiated: 07/23/2024. Revision on: 08/03/2024. The goal, the resident will remain free of complications or discomfort related to Hemiplegia. Interventions read in part . Assist with ADL's/Mobility as needed. Date Initiated: 07/23/2024 CNA . Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments . Record review of the Facility Incident Intake #: 534855 reflected in part . Resident alleges CNA was rough during transfer. Actions and Notifications CNA suspended, resident assessed, MD, RP notified . Record review of the facility investigation worksheet in Tulip (the online system for submitting long term care information) revealed read in part . Intake ID 534855 .Priority Facility 45-day Priority Date: 9/30/2024 , Received Date 09/30/2024 Final Report Received: False. Record review revealed that there was no final 3613 (provider investigation report) submitted into Tulip for facility incident intake #: 534855 submitted on 9/30/2024. Record review of the facility incident/accident report revealed on 9/30/2024 an incident under the category other. An interview on 10/14/2024 at 12:28 p.m. with the Administrator, she said that the facility had the initial 3613 incident submitted but did not have the final 3616 submitted. During an interview on 10/15/2024 at 9:57 a.m., with the Administrator, she confirmed that there was no final 3613 investigation report submitted for incident #: 534855. She said the former DON said that she submitted the final 3613 thinking that she had but it was not submitted. When asked about a possible negative outcome if the final 3613 was not submitted, she said she always submitted her reports,, She said the investigation was completed but was not submitted. An interview on 11/15/2024 at 3:12 p.m. with the DON, she said that the Administrator planned to train her to submit facility investigation reports into Tulip soon, being that she was recently hired she had not had training. Record review of the facility policy and procedure entitled Reporting Events; Home Office and State read reflected in part . Guidelines for reporting incidents to DADS is contained in Provider Letter 19-17 dated 7/10/19. Record review of Long-Term Care Regulatory Provider Letter 19-17 date issued: July 10, 2019, read in part . This letter provides guidance for reporting incidents to HHSC (Health and Human Services Commission) . A NF (Nursing Facility) must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse . In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring. 4. A provider must submit a PIR (Provider Investigation Report) to CII (Complaint and Incident Intake) using HHSC Form 3613-A (for use by an NF) . or HHSC Form 361 . The PIR must include all information from the initial incident report and any additional information the provider has obtained since making the initial report, including witness statements. The provider must submit the PIR within the applicable required time frame, as follows: Five working days for an NF or skilled NF .

Based on observation, interview, and record review, the facility failed to have a person-centered comprehensive care plan developed and implemented to meet each resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for 1 of (Resident #42) 6 residents reviewed for care plans. - Resident #42's comprehensive centered care plan revealed that resident was not being care planned for foot care. This failure placed resident at risk for not having their individual medical needs met. Findings Included: Record review of Resident #42's face sheet dated 11/15/2024 revealed a [AGE] year-old male admitted to the NF on 10/04/2023. Resident diagnoses included Alzheimer's Disease (disease that destroys memory and other mental functions), cerebral infarction (when blood flow to the brain is blocked), hemiplegia and hemiparesis (condition that causes paralysis or weakness), and type 2 diabetes mellitus (long term condition where the body has trouble controlling blood sugar and using it for energy). Record review of Resident #42's admission MDS dated [DATE] reflected a BIMS score of 14 indicating the resident's cognition was intact. Further review of section GG (Functional Abilities) reflected the resident required moderate assistance with personal hygiene. Record review of Resident #42's Physician Order for June 2024 reflected the following: -Dated 06/10/2024 May have Podiatry (medical field that specializes in the treatment and diagnosis of foot care, ankle, and lower limb disorders) consult PRN. Record review of Resident #42's comprehensive centered care plan 09/18/2024 reflected that resident was not care planned for podiatry services/foot care. Record review of the NF residents on the list for podiatry services for the month of 10/02/2024, did not included Resident #42. Further review reflected the next time podiatry services to return to the NF was 12/04/2024. Observation on 11/12/24 at 9:40 a.m. revealed Resident #42 resting in bed awake, alert and oriented times 3. Further observation was conducted of the resident's feet being exposed. Resident #42's right foot great toenail appeared calcified (thick and dry) and long. The 3rd and 4th toenails to the right foot was thick, long and curved. Observation of the resident's left foot great toenail revealed it long. The 2nd and 4th toenails appeared thick, long and curved. Interview on 11/15/2024 at 1:47 p.m. the MDS Coordinator said she done the initial care plans and the quarterly care plans. The MDS Coordinator said it was the unit nurses, ADON or DON that done any revisions or acute care plans . Observation on 11/13/24 at 2:18 p.m. revealed Resident #42's toenails with ADON B said some of the toenails were long and thick and beginning to curve. Interview on 11/15/24 at 1:59 p.m. ADON B said she updated the resident care plan for psych medications (medications to treat mental disorders), dietary, and the Infection Control Nurse done any revisions that involved changes in the resident care. Interview on 11/15/24 at 2:05 p.m. the DON said anyone that was on the IDT (consisted of the nursing department, physical therapy, social worker, and anyone involved in the resident care) could update a resident care plan. The DON said it was ultimately the MDS Nurse Coordinator's responsibility to make sure that each resident had a comprehensive centered care plan addressing each resident needs. The DON said if the resident needs were not being address in the care plan, it placed the resident (s) at risk for lack of care. Interview on 11/15/24 at 2:20 p.m. the Social Worker said no one had informed her that Resident #42 needed podiatry services therefore it would not trigger for her to care plan. The Social Worker said now that she had been made aware that Resident #42 needed podiatry services, she would make sure that Resident #42 was added to the list and care planned as well. Record review of the NF policy on Comprehensive Centered Care Plans not dated reflected in part: .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preference and needs of the residence and in response to current interventions .Interdisciplinary means that professionals disciplines, as appropriate, will work together to provide the greatest benefits to the resident .

Based on observation, interview, and record review the facility failed to ensure that residents received proper treatment and care to maintain mobillity and good foot health for 1 (Resident # 42) pf 6 residents reviewed for foot care. -The facility failed to provide Resident #42 who had diabetes mellitus podiatry services. This failure placed resident at risk for injuries, infections, unwanted hospitalization , and amputation leading to a decrease in quality of life. Findings Included: Record review of Resident #42's face sheet dated 11/15/2024 revealed a [AGE] year-old male admitted to the NF on 10/04/2023. Resident diagnoses included Alzheimer's Disease (disease that destroys memory and other mental functions), cerebral infarction (when blood flow to the brain is blocked), hemiplegia and hemiparesis (condition that causes paralysis or weakness), and type 2 diabetes mellitus (long term condition where the body has trouble controlling blood sugar and using it for energy). Record review of Resident #42's admission MDS dated [DATE] reflected a BIMS score 14 indicating the resident cognition was intact. Further review section GG (Functional Abilities) reflected the resident required moderate assistance with personal hygiene. Record review of Resident #42's Physician Order for the month of June 2024 reflected the following: -Dated 06/10/2024 May have podiatry (medical field that specializes in the treatment and diagnosis of foot care, ankle, and lower limb disorders) consult PRN. Record review of the NF residents on the list for Podiatry services for the month of October 02, 2024, did not included Resident #42. Further review reflected the next time Podiatry services to return to the NF was December 04, 2024. Record review of Resident #42's shower sheet dated 11/11/2024 CNA D documented the resident was given a bed bath. Further review reflected that CNA D documented the resident's fingernails were cleaned and clipped and the resident's toenails were clean and did not need to be clipped. Observation on 11/12/24 at 9:40 a.m. of Resident #42 resting in bed awake alert and oriented times 3. Further observation was conducted of resident feet being exposed. Resident right foot great toenail appeared calcified (thick and dry) and long, 3rd and 4th toenail to right foot was thick and long and curved. Observation of resident left foot great toenail long, 2nd and 4th toenail appeared think, long and curved. Interview on 11/12/2024 at 9:40 a.m. Resident #42 said he could not remember the last time he had been seen by the podiatrist. Resident #42 said he would like for his toenails to be clipped. The resident denied any discomfort to his toenails. Observation on 11/13/24 at 2:18 p.m. of Resident #42's toenails with ADON B said some of the toenails were long and thick and beginning to curve. Interview on 11/13/2024 at 2:18 p.m. ADON B said the nurses were supposed to do a head-to-toe assessment on the residents every week. ADON B said when providing the residents a shower the CNA's should be reporting to the nurse if the resident's toenails need to be clipped. ADON B said the nurse would then contact the Social Worker to add a resident to the list to be seen by the podiatrist (a doctor who specializes in the diagnoses and treatment of foot, ankle, and lower limb disorders). ADON B said if a resident's toenails were not being groomed, the toenail would continue to grow and began to curve into the resident skin placing resident at risk for injuries. Interview on 11/13/24 at 2:38 p.m. CNA C said she was Resident #42's CNA. CNA C said Resident #42 received his showers on Tuesdays, Thursdays, and Saturdays. CNA C said she had documented on the resident shower sheet about toenails needing to be clipped but could not remember when she documented this and who she reported it to. Interview on 11/13/24 at 2:47 p.m. CNA D said she worked at the facility on the 6:00 p.m. - 6:00 a.m. but came to the facility to work an extra shift. CNA D said she did not report to the nurse that Resident #42's toenails needed to be clipped and must have forgot. CNA D said it was important to communicate with the nurse if the resident's toenails needed to be clipped because the resident could get an infection. Interview on 11/13/24 at 2:55 p.m. the Social Worker, after reviewing her list of residents to be seen by pPodiatry services, said Resident #42 was not on the list to be seen by pPodiatry services. The Social Worker said records showed that the last time podiatry services was at the facility was 10/02/2024, and before that date she believed it was 09/11/2024. The Social Worker said she thought the next time podiatry services would be back at the facility was 12/04/2024. The Social Worker said podiatry services came to the NF at least every 2-3 months. Interview on 11/13/2024 at 4:03 p.m. with LVN N said the residents' skin was assessed on a weekly basis by performing a head to the toe. LVN N said she was Resident #42's nurse. LVN N said she had not done a head-to-toe assessment on Resident #42 because the system in point click care did not trigger for her to do so. LVN N said after reviewing resident weekly skin assessment with last one done on 11/07/24 reflected no skin breakdown. LVN N said a resident who had diabetes and was not being followed by pPodiatrist services put the resident at risk for infections, sepsis(life-threateng infection that could lead to death), and could escalate from there. Interview on 11/13/2024 at 4:38 p.m. the DON said regarding podiatry services, she would have to review the NF policy. The DON said the nurses should be performing weekly skin assessments and reviewing the CNAs's shower sheets for any changes toin the resident's condition. The DON said if there was a change in a resident's condition regarding nail care, the unit nurse needed to alert the wound care nurse who would then alert social services for the resident to be added to the list for podiatry services. The DON said when residents were not being assessed in a timely manner, it placed residents who had diabetes and required podiatry services at risk for infections, hospitalization , and amputation. The DON said unfortunately, she was still learning the facility process and would be in-servicing her staff as well as implementing a plan to ensure that residents were being assessed properly and care was being provided in a timely manner. Interview on 11/14/2024 at 9:47 a.m. the Wound Care Nurse said she done the initial skin assessments on all new and readmitted residents and the unit nurses done the weekly skin assessments on the residents. The Wound Care Nurse said that it was important for a resident who had a diagnosis of diabetes be placed on podiatry services to care for the resident's toenails and fingernails to ensure that the resident's nails were being groomed properly and to avoid injuries to the resident. The Wound Care Nurse said nail care was extremely important for a resident who had diabetes because of the risk of injuries, infections, and poor blood circulation particularly in the lower extremities. The Wound Care Nurse said if the resident developed an injury or infection to the lower extremity, it could lead to hospitalization . The Wound Care Nurse said diabetes was the number cause of amputation. Record review of the NF policy on Foot Care, not dated, reflected the following: .Foot management is the daily assessment, bathing, lubrication, and protecting of the feet. It is done to promote cleanliness and peripheral (away from the center of the body, example the hands and toes) circulation of the feet. Foot care is especially important in those residents with diabetes mellitus or peripheral circulatory conditions because of the susceptibility to infection and skin breakdown. If required, trimming of the toenails is performed by a Podiatrist ( .Become familiar with medical conditions that compromise circulation in the feet and assess for need of nail trimming. Request referral to Podiatrist if nail trimming is needed .

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 4 residents (Resident #20) reviewed for respiratory therapy in that: 1. The facility failed to ensure Resident #20's oxygen was set according to physician's orders. This failure could place residents at risk of respiratory distress. The findings were: Record review of Resident #20's sheet dated 11/15/2024 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #20 had diagnoses included: cerebral infarction (when blood flow to the brain is disrupted, causing brain tissue damage.), hypertension (when the blood pressure in the blood vessels is too high), and cerebrovascular disease (condition [NAME] affect the blood vessels and blood flow in the brain and spinal cord). Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 had BIMS of 06 out of 15 which indicated severely impaired cognition. Durther review revealed Resident #20 was on oxygen therapy. Record review of Resident #20's care plan dated 06/03/2024 revealed the resident had shortness of breath hypoxia(when the body's tissues are not receiving enough oxygen) O2 at 1-2 L via NC continuous to maintain O2 sats >92%. Intervention: monitor /document changes in orientation, increased restlessness, anxiety, and air hunger(uncomfortable sensation of not being able to get enough air). Record review of Resident #20's order summary report dated November 2024 reflected in part . O2 at 1 to 2 liters via NC continuous to maintain O2 sats >than 92% start date 09/18/24 . Record review of Resident #20's MAR for November 2024 revealed the resident was on O2 @ 1-2 L via NC continuous to maintain O2 sats > 92%; every shift for hypoxia and was signed off but the oxygen saturation was not documented. During an observation and interview on 11/12/2024 at 10:28 a.m., revealed Resident #20's oxygen concentrator was set at 3.5L. Resident #20 had difficulty with speech but was able to say no when she was asked if she knew how many liters of oxygen she was supposed to be on. Resident #20 also said no when she was asked if she had changed the setting on the concentrator. Resident #20 did not appear to be in any distress at the time. During an interview on 11/12/2024 at 10:35 a.m., RN R said Resident #20's oxygen was set at 3.5 L. RN R said Resident #20's concentrator should be set at 2 L, but she was not sure and said she would check where the oxygen should be set at. RN R returned at 10:37 a.m., saying the oxygen setting should be between 1 and 2 L. During an interview on 11/13/2024 at 11:26 a.m., RN R said she did initial rounding when she came to work today at 7:00 a.m. during the start of her shift, and she forgot to check the oxygen setting on the concentrator. RN R said the setting on the concentrator was not what the physician ordered for Resident #20, which meant the physician's order was not followed. RN R said Resident #20 was given more oxygen than ordered. Resident #20 could become hyperventilated(breathing faster and deeper than the body needs). RN R said that could cause Resident #20 to depend on oxygen, and it would be difficult to wean Resident #20 from using oxygen. RN R said the DON monitored nurses during rounding. RN R said she had a skills check-off and in-service on oxygen administration. Record review of the facility nurse proficiency audit dated 06/03/2024 revealed RN R signed the audit, and it included oxygen administration and maintenance. During an interview on 11/13/2024 at 11:38 a.m., ADON A said the nurses monitored the oxygen setting on the concentrator during rounding. ADON A said if Resident #20's oxygen was above the physician's order, then Resident #20 was not receiving oxygen as ordered. ADON A said if Resident #20 received more oxygen than ordered, it could lead to hyperoxygenation(overbreathing), which could cause a change in the condition of Resident #20 breathing. ADON A said RN R should have done the skills- check-off, which included oxygen administration and monitoring before working with residents who were on oxygen. ADON A said the ADON monitored the nurses during random rounds. ADON A said nurses should check on the oxygen concentrator setting every two hours when they make rounds. During an interview on 11/14/2024 at 7:50 a.m., the DON said RN R should check the oxygen setting on Resident #20's concentrator every 2 hours during rounding. The DON said the oxygen concentrator for Resident #20 should be set according to the physician's order. The DON said that for a resident to be on oxygen, the resident would have a physician's order and that the nurse should follow the physician. The DON said if Resident #20 was given more oxygen than was ordered, then Resident #20 could have hyperventilated respiratory distress, and Resident #20 lungs could be affected. During an interview on 11/15/2024 at 10:26 a.m., NP Z said RN R must notify the physician's order before the nurses would increase Resident #20's oxygen. NP Z said Resident #20 could get micro changes in her eyes(vision changes ) if Resident #20 were administered more oxygen than ordered. NP Z said Resident #20 could become lethargic and feel dizzy. NP Z said he was not notified about the increase in Resident #20 oxygen setting. Record review of the facility oxygen administration nursing policy and procedure manual 2003 Rev March 21, 2023, reflected in part . the mount of oxygen by percent of concentration or L/min, and the method of administration is ordered by the physician .

Based on observation, interview, and record review , the facility failed to ensure a resident who entered the facility with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development or worsen of pressure ulcers for 2 of 2 resident (CR #3 and Resident #1) reviewed for pressure ulcers. The facility did not provide treatment to CR#3's bilateral heels facility acquired Stage 3 pressure ulcer for three days. The facility did not provide wound care/ treatment to CR#3's buttocks wound for 5 days resulting in the worsening of her wounds and delayed treatment. The facility failed to implement Resident #1' s orders for his pressure ulcer treatment. These failures could place other resident with pressure ulcers at risk of developing new pressure ulcers and decline in existing pressure ulcers. Findings included: CR #3 Record review of the face sheet for CR#3 revealed she was [AGE] years old. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #3' s admission MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderately impaired cognition. She needed extensive assistance of two staff with bed mobility, toilet use, and personal hygiene. She was incontinent of bladder and bowel. CR #3 was totally dependent on staff for transfers. The MDS indicated CR#3 was at risk of pressure ulcers. Record review of CR #3's care plan identified the resident had physical functional deficit related [MEDICAL CONDITION]( Cerebro Vascular Accident) with residual effects , left [MEDICAL CONDITION] and need moderate to extensive assistance with ADLs (Activities of Daily Living ) . Care plan was initiated 12/3/2019. Record review of CR #3' s records revealed no care plan following her admission addressing CR#3's pressure ulcer risk . CR#3 had a care plan initiated 12/29/19 and revised 1/14/2020 . Record review of CR #3's admission skin assessment dated [DATE] titled Nursing-Weekly pressure Ulcer Evaluation revealed CR #3's skin was intact and on pressure sores. No further weekly skin assessment was documented as completed presented till 12/23/19. Record review of Weekly Nurses Note dated 12/23/19 at 11:52 p.m., revealed summary had wound nurse to look at BLE heels and her buttock This was written by LVN #1 to treatment nurse who no longer works with the facility. Record review of CR#3's general notes per treatment nurse revealed on 12/25/2019 at 11:09 a.m. CR #3 has SDTI ( Suspected Deep Tissue Injury) to bilateral heels. Verbal order received from NP for skin prep twice a day. Will continue to monitor till resolved. Responsible Party (RP) was notified. Further review of CR#3's orders revealed there was no order for the buttock wound. Record review of CR#3's general notes per treatment nurse dated 12/26/2019 at 2:36 p.m. revealed CR #3 had SDTI on right and left heel. Right heel measures 5.2 cm x 4.2 cm x 0.0 cm and left heel measures 4.2 cm x 4.5 cm x 0.0 cm. Continue treatment twice a day till resolved. Record review of CR#3's general notes per NP (Nurse Practitioner) dated 12/27/2019 at 10:43 a.m. revealed order offload boots to be worn at all times. Record review of CR#3's general note dated 12/27/2019 at 1:30 p.m. revealed CR #3 had an open wound on her buttocks. Per former DON, open wound was unstageable. NP notified and gave orders to cleanse wound and apply santyl ( chemical debridement agent) and calcium alginate daily. NP also states CR#3 was to be up for all meals and then back in bed between meals and to get an air mattress for CR #3. RP notified. No measurement for the open wound to the buttock. Record review of CR#3's general note dated 12/30/2019 08:39 a.m. revealed per treatment nurse NP ordered, Air mattress received. Provolone boots are on bilateral feet. NP in the facility and evaluated wound on patient's buttocks. CR #3 was repositioned to her left side with a wedge in place and had referral to the wound care doctor. Record review of CR#3's general note dated 12/31/2019 5:12 p.m. revealed late entry: per treatment nurse revealed CR #3 was seen by wound care Dr. CR #3 had bilateral unstageable areas to heels. Right heel measured 5.7 cm x 6.6 cm cx 0.0 cm with 50% necrotic tissue and 50 % granulated tissue and left heel measured 5.2 cm x 4.9 cm x 0.0 cm with 60% necrotic tissue and 40% granulation tissue. Continue current order. CR #3also had area to right buttocks measuring 6.6 cm x 6.4 cm x 0.1 cm with moderate drainage with 40% necrotic tissue, 40% slough and 20% granulation. Continue with current treatment. Will continue to monitor till resolved. Record review of CR#3's general note dated 1/7/2020 5:23 p.m. revealed CR #3 was seen by wound care Dr. CR#3 had area to right heel measuring 6.1 cm x 7.2 cm x 0.0 cm. Right heel is unstageable with 40% [MEDICATION NAME] and 60% necrotic. Left heel measured 6.1 cm x 5.4 cm x 0.0 cm and is unstageable. 30% [MEDICATION NAME] and 70% necrotic. Left buttocks have area measuring 6.8 cm x 4.7 cm x 0.2 cm and unstageable. 40% slough, 20% [MEDICATION NAME] and 40% granulation. New area to left malleolus (the bony prominence on each side of the ankle) measuring 2.0 cm x 1. 1 cm x 0.0 cm. Unstageable. 20% [MEDICATION NAME] and 80% necrotic. Order skin prep. Record review of CR #3's TAR wound care revealed no documentation or initials indicating wound care and dressing changes were done on 1/5/20, 1/7/20, 1/18/20 and 1/19/20 and there were no documentation indicating CR#3 had refused wound care and wound dressing changes. Record review of CR#3's hospital record dated 1/21/2020 revealed chief complaint was gradually worsening chronic decubitus pressure ulcer. Further review revealed a [AGE] year-old female with bilateral stroke living in a nursing home in the katy area. She had developed wound in the ischial (hip bone) which has been getting worse and had started to smell. Assessment and plan revealed right hip bone pressure ulcer , has possible complication to the rectum and massive necrosis with associated [MEDICAL CONDITION], acute [MEDICAL CONDITION] and dehydration. Poor mobility also led to wounds on both heels. Plans are for aggressive debridement of the necrotic wound and antibiotic therapy for aerobic and anaerobic infection, rehydrate and correct the prerenal stage . she will need a diverting [MEDICAL CONDITION] and aggressive debridement of the wound . Flap closure but she overall was poor . Interview on 3/4/20 at 2:38 p.m., the DON said the facility did not have a treatment nurse, she said each floor nurse was responsible for wound care and performed wound treatments. The DON said she was not sure if floor nurses had been in-serviced because the treatment nurse was terminated, and former DON quit. She said she was new in the position of DON. The facility just hired a new treatment nurse a couple of weeks ago. In an interview with the NP who returned a call placed on 3/4/2020 at 11:30 a.m., she said she gave orders for CR #3's wounds when the nurse notified her of the unstageable pressure sores. NP returned all on 3/10/2020. Resident #1 Record review of Resident #1 admission face sheet revealed she was a [AGE] years male who was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review Resident #1's quarterly MDS assessment, dated 2/13/20, reflected Resident #1 was admitted with no pressure ulcer. The MDS also revealed Resident #1 required total assistance from two or more staff for bed mobility and toilet use. Section H identified Resident # 1 as incontinent of bladder and bowel and had a BIMS score was 13 indicating moderately impaired with decision making skills. Record review of Resident #1's care plan last revised on 2/13/20 indicated Resident #1 required extensive assistance with ADLs. He was at risk for further skin breakdown. Interventions included weekly skin assessment and documentation , a low air loss mattress while in bed, and a wheelchair cushion while in wheelchair. Record review of Resident #1's pressure wound log dated 2/3/2020 at 6:13p.m., revealed During dressing to lower ext. after resident shower, a skin assessment was completed and resident noted with 6cm x4cm area of left inner buttocks, and SDTI of right heel measuring approx. 3 x 2cm. area of buttocks cleanse with NS and covered with dry dressing. Right heel cleanse with NS and skin prep applied and left open to air. Also noted scab formation of right outer ankle measuring 0.5x 0.5cm. RP and Np notified of new areas and orders received for treatment. Refer to wound MD. Record review of Resident #1's order dated 2/3/20 revealed an order from the NP to cleanse left ischial with Vashe ( a wound cleansing solution) pat dry apply medi-honey, silver alginate, gauze, and dry dressing daily. Observation and interview on 3/4/20 at 10:54 a.m. revealed Resident #1 was lying in bed on a pressure relief mattress . Resident #1 had head to toe assessment done by LVN #2 which revealed no dressing to left ischium. LVN #2 said she was not aware when the dressing came off. LVN #2 said the dressing could have come off during incontinent care and normally the floor nurses would replace the dressing if it comes off. LVN #2 said the dressing was done on 3/3/20 at 9:00 a.m. In an interview on 3/4/20 at 11:00 a.m., Resident #1 said he did not know that the wound dressing was off and he did not know when the dressing came off . In an interview with CNA #1 on 3/4/20 at 11:15 a.m. she said she had been working in the facility since 2016 . She said she provided incontinent care for Resident #1 . She stated that resident did not have any wound dressing to his right ischial area when she provided incontinent care to him. She also said the resident was wet with urine at that time. CNA #1 said she would notified the nurse if dressing came off. In an interview with LVN # 1/Treatment nurse on 3/4/20 at 11:30 a.m. , she said she started work January 2020 and she was the only treatment nurse. She said she performed weekly skin assessments and only had Resident #1 with an in house acquired pressure ulcer to right ischium and right heel. She further said Resident #1 goes to wound care center once a week and the doctor at the wound care center was the wound doctor the facility used. She further said the wound doctor visited every Tuesday and does wound debridement . In an interview with the DON on 3/4/20 at 4:30 p.m., the DON said she was new to the facility and heard about CR#3. She said the facility had a QAPI following CR#3's wound concerns. The DON said the facility did not have a policy regarding following physician's orders [REDACTED].>In an interview with the facility administrator on 3/4/20 at 5:30p.m. regarding CR#3 and Resident #1's pressure sores treatment, she said no matter what the facility does or tries to do, the facility would be cited. Even when the facility had QAPI and audit conducted regarding in house acquired pressure areas. Record review of the QAPI presented by the administrator revealed it was dated 2/27/2020. Further review of the QAPI following authorization the DON indicted the facility conducted an audit on all residents , identifying those at-risk pressure ulcers as well as those with pressure ulcers to ensure treatment were in place. The DON/ADON will make round to compare resident 's positioning and care plan for four weeks. The facility hired a more experienced wound care nurse to ensure weekly skin assessment were done and reported weekly to the DON during daily stand up meetings. Overall number of facility acquired wounds had decreased and healed. Record review of the facility's Skin Care Guideline (July 2018) read in part, .The purpose of this procedure is to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. Process . Weekly review of the patient's /resident's skin will be completed by the nurse and documented in the electronic medical record. When an open area is identified: Implement resident specific interventions immediately. Specialty mattress/pressure reduction mattress on bed Notify physician and document notification.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one of 28 residents (CR #98) reviewed for quality of care, in that; CR#98 who was cognitively impaired, known to be at risk of falls, sustained four falls with head injuries and was identified to require one on one supervision and monitoring which was not provided. CR#98 had a fall with head injury on 2/5/19 and had a change in condition three days after which was not identified for prompt intervention . CR#98's radiology recommendation for CT Scan was not implemented after the change in condition occurred. CR#98 was found unresponsive the following morning and transferred to the hospital where he was diagnosed with [REDACTED]. On 2/15/2019, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 2/20/2019, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected one closed record who remained in the hospital ICU . Findings included: CR #98 Record review of CR #98's face sheet revealed a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #98's nurses notes dated 11/9/18 at 10:20PM revealed, admitted to the facility from hospital; Diagnoses: [REDACTED]. Alert and oriented X 1; notified family of resident's arrival; [MEDICATION NAME] and [MEDICATION NAME] consents filed. Will continue to monitor; bed lowered to lowest position. Resident noted to [MEDICAL CONDITION]; minimal discoloration noted to chest area. Record review of CR #98's NP initial visit notes dated 11/10/18 revealed in part, Patient is seen and examined to evaluate nurses concerns about generalized weakness, difficulty walking upon admission. Patient was admitted to hospital for heat stroke. During the course of this hospitalization , patient was managed for acute [MEDICAL CONDITION], weakness, [MEDICAL CONDITION]. Patient has a medical history of [REDACTED]. Further review of the note revealed in part, patient is at risk of falling, medications is reviewed frequently, nursing staff is asses (SIC) and adjusting care as needed to accommodate the fall risks. The NP noted the treatment plan for CR #98's [MEDICAL CONDITION] was for him to be evaluated and treated by PT if he had new onset of decrease in strength, decline in physical and functional mobility, reduced ability to safely ambulate and transfer, and increased need for assistance with ADL's. The note reflected the treatment plan for generalized weakness was for OT to evaluate and treat CR #98 to improve his ADL's and functional status. Record review of CR #98's Admission Minimum Data Set ((MDS) dated [DATE] revealed CR#98 was severely impaired for cognitive skills and had short- and long-term memory problems. The MDS revealed CR #98 had fluctuating episodes of disorganized thinking and had behavioral symptoms not directed towards others which occurred 1 to 3 days. The MDS revealed CR#98's behavioral symptoms placed him at risk for physical illness or injury. The MDS revealed CR #98 required total dependence with two persons physical assist for transfer, locomotion on unit and locomotion off unit. CR #98 was unsteady, only able to stabilize with staff assistance, walking activity did not occur, and he was unsteady for surface - to - surface transfer. CR#98 used mobility device - wheel chair. Further review of MDS revealed the resident had a fall with injury that was not major . Record review of CR #98's undated Care Plan revealed, in part; Focus: I am at increased risk for falls related to (r/t) decreased safety awareness, impulsivity, and Poor communication/comprehension. 11/15/18 fall with abrasion to forehead. 12/12/18 fall no injury. 12/25/18 fall no injury. 1/6/19 fall continue Occupational Therapy (OT) services. 1/13/19 fall with abrasion to forehead. 1/15/19 fall no injury. 1/17/19 fall no injury. 1/21/19 fall sent to emergency room (ER). 1/31/19 fall no injury. 2/5/19 fall no injury. Goal: I will not sustain serious injury r/t a fall through the review date. Intervention/Tasks: 11/15/18 scoop mattress for safety 12/12/18 high back w/c 12/25/18 OT to evaluate and treat. 1/6/19 PT/ ST screen. 1/13/19 Physical Therapy (PT)/ OT screen, PT to treat. 1/15/19 Labs. 1/17/19 PT/ OT/ Speech therapy (ST) screen. 1/21/19 antibiotic therapy (ABT) for urinary tract infection [MEDICAL CONDITION]. 1/31/19- anti-slip sheet to wheel chair (w/c). Anticipate and meet the resident's needs Assist me with routine and as needed toileting Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Drug regimen review performed. Keep bed in low position. PT evaluate and treat as ordered or as needed (PRN). Focus: I have an ADL self-care performance deficit r/t cognitive impairment. Goal: My needs will be met through review date. Intervention/Tasks: I use a w/c for mobility. I am dependent on propulsion. Bed Mobility: one-person physical assist. Toilet Use: The resident is totally dependent on one staff for toilet use. Transfer: the resident is able to assist with transfer. One person assists. PT/OT evaluation and treatment as per doctor (MD) orders. Focus: I have behavioral issues r/t impulsivity and pulling at enteral feed tube. Goal: I will not have unidentified complications r/t my behaviors through the review date. Intervention/Tasks: Administer medication as ordered. Monitor/document for side effects and effectiveness. Explain all procedures to the resident and allow the resident to adjust to changes. If reasonable, discuss behavior. Explain/reinforce why behavior can increase risk for fall/interruption of feed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations. Document behavior and potential causes . Record review of CR #98's Occupational Therapy Discharge Summary revealed he started services on 11/13/18 and was discharged from services on 11/26/18. The summary revealed CR #98's clinical reasoning for OT services was to increase sitting balance during ADL's and to be fitted for wheel chair to spend time out of bed. Record review of CR #98's NP progress notes dated 11/15/18 revealed he was evaluated for acute on chronic disease management and tolerance with increased physical activity. Further review of the note revealed in part, Patient is seen, examined and his progress in therapy need reviewed. Patients medical history is also being evaluated to promote full participation in therapy. Patient is showing some progress in therapy per therapist report. Patient is stable, no reports of nausea, vomiting, headache. The note reflected treatment for [REDACTED]. Record review of CR #98's nurse's notes dated 11/15/18 at 6:05PM revealed, Resident is alert oriented x2, with confusions, had unwitnessed fall at 5:00PM. He was observed on the floor by the bedside lying on his back, sustained a skin opening on the right side of his forehead and is bleeding. Vital signs Blood Pressure (BP) 118/81, Pulse 87, Respiration 19, Temperature 99.3, and O2 Saturation 97% on room air. Nurse Practitioner (NP) was notified who ordered to send the resident to the emergency room (ER) for further evaluation and management. Record review of CR #98's incident report dated 11/15/18 at 5:49PM revealed resident had an unwitnessed fall in his room. Report narrative revealed the resident was alert and oriented x2 and had confusion. He had an unwitnessed fall at 5:00PM where he was observed on the floor at his bedside lying on his back. He sustained a skin opening on the right side of his forehead and is bleeding. NP was notified who ordered to send the resident out to the ER for further evaluation and management. The resident had an abrades area with bleeding to the right side of the forehead, there was no hematoma noted. Listed medical risk factors related to the incident included: fall history, inability to understand directions, substance abuse, confusion/disorientation, incontinency, sensory limitations, and tremors/[MEDICAL CONDITION]. Record review of CR #98's hospital after visit summary dated 11/15/18 revealed the reason for visit was for a fall. He was diagnosed with [REDACTED]. Instructions were to follow up with his primary care provider, Tylenol as needed, clean wound twice a day, and to return to ER for any further problems or concerns. Record review of CR #98's nurse's notes dated 11/16/18 at 12:12AM revealed, Resident returned from the hospital ER at 12:00AM with the [DIAGNOSES REDACTED]. Abrasion of scalp was clean, and [MEDICATION NAME] was applied. Resident was given [MEDICATION NAME] while in the ER. NP was notified. Resident in bed, bed in low position and call light within reach. BP 126/78, Pulse 84, Respiration 18, Temperature 97.8. Resident remains stable at this time with no distress noted. Will continue with plan of care. Record review of CR #98's NP progress notes dated 11/16/18 revealed she saw and examined the resident at his bedside per the nurses report of abrasion to forehead. The treatment listed for the abrasion was to cleanse abrasion to forehead with NS (Normal saline), pad dry, apply TAO (triple antibiotic ointment) and dressing. Record review of CR #98's NP progress notes dated 11/19/18 revealed he was evaluated for acute on chronic disease management and tolerance with increased physical activity. Further review of the note revealed in part, Patient is seen, examined and his progress in therapy need reviewed. Patients medical and physical condition is also being evaluated to promote full participation in therapy. Patient is showing some progress in therapy per therapist report. Patient is stable, no reports of nausea, vomiting, headache. The note reflected treatment for [REDACTED]. Record review of CR #98's NP progress notes from 11/23/18 to 12/10/18 revealed ongoing evaluation of current treatment for [REDACTED]. Record review of CR #98's records revealed the resident was discharged from OT on 11/26/18. OT was re-started on 1/2/19. Record review of CR #98's nurse's notes dated 12/12/18 at 12:43PM revealed, writer found resident lying on the floor by his bed. No injuries noted. No pain in extremities noted during movement. Bed was in low position. Resident denies pain. Neuro-check in progress. Vital signs BP 107/64, pulse 67, Respiration 20, Temperature 97.9. NP and Responsible party (RP) notified. Will continue to monitor. Record review of CR #98's incident report dated 12/12/18 at 12:01PM revealed the resident had an unwitnessed fall in his room where he fell from bed to floor. The resident was observed lying on the floor on the side of his bed. Head to toe assessment was done with no noted injuries. There was no pain in extremities noted during movement. The bed was in low position and the resident denied pain, neuro-checks were in progress. Listed medical risk factors related to the incident included: fall history, inability to understand directions, incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: night light, bed in low position, physical therapy, call light within reach, psych evaluation, and pain assessment. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach. Record review of CR #98's NP progress notes dated 12/14/18 revealed no change in treatment or fall interventions. Record review of CR #98's nurses notes dated 12/18/19 at 10:22AM revealed, Resident was getting up to wheel chair during this shift. Resident was trying to get up by self from wheel chair while was sitting at nursing station. When writer was trying to redirect resident, he screamed get out of me, do not touch me. Writer asked is resident wants to go back to bed, he agreed. Resident resting in a bed at this time, with no distress noted. Vital signs stable. Will continue to monitor. Record review of CR #98's nurses notes dated 12/19/18 at 1:34PM revealed, Resident was up to w/c this morning. Resident was trying to get up, redirected by writer with success. Resident was sitting in wheel chair for 40 minutes. The writer asked if resident wants to go to bed, resident agreed. No distress, no pain noted. Will continue with plan of care. Record review of CR #98's nurses notes dated 12/25/18 at 8:45AM revealed, Writer observed resident lying on the floor at bedside. No injuries noted, no pain in extremities during movement noted. Bed was in low position. Resident denies any pain, discomfort. Neuro check in progress. Vital signs BP 149/75, pulse 71, Respiration 20, Temperature 97.9. NP and RP notified. Will continue to monitor. Record review of CR #98's incident report dated 12/25/18 at 8:45AM revealed he had an unwitnessed fall in his bed where he fell from his bed to the floor. Resident was observed on the floor in his room at his bedside. He denied pain and discomfort. His vitals were BP 149/75, pulse 71, Respiration 20, and Temperature 97.9. There was no pain noted during movement of his extremities. No injuries were noted. Medical risk factors possibly related to incident were listed as, fall history, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: bed in low position, call light within reach, and pain assessment. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach. Further review of post fall assessment revealed no change in interventions. Record review of CR #98's Occupational Therapy Discharge Summary revealed he started services on 1/2/19 through 2/4/19. The summary revealed CR #98 clinical reasoning for OT services was for his ADL scores and clinical judgement. Record review of CR #98's nurses notes dated 1/6/19 at 6:50PM revealed, 1/6/19 at 6:00PM, patient noted quickly sliding from low bed, confused conversation per usual, denies pain, stated was trying to get to other bed and that it looks comfortable. Bilateral lower/upper extremities passive range of motion (PROM) intact, no apparent injuries noted. Assist back to bed with two persons assist. Vital signs: temperature 97.6, Pulse 64, respirations 19, BP 11/54, O2 (Oxygen) saturation 97%. NP updated, to monitor, RP updated, ADON updated, will continue to monitor. No acute distress noted. Low bed maintained, warm blanket provided per request for comfortable bed. Record review of CR #98's nurses notes dated 1/6/19 at 6:30PM revealed he had an unwitnessed fall in his room from his bed to the floor. While nurse was passing the residents room he noted the CR #98 sliding from bed to lie on his right side, bed was in low position and he stated he wanted to get to the other bed. He was assessed with [REDACTED]. Record review of CR #98's post fall assessment dated [DATE] revealed prior to the fall, resident was doing usual activities, reaching down, and had tremors. Recommendations and interventions post fall: bed in low position, physical therapy, call light within reach, assistive device within reach, pain assessment, and keep warm blanket on. Interventions to be implemented to minimize risk of occurrence: offer warm blanket for comfort to keep warm Further review of post fall assessment revealed no change in interventions from falls on 12/12/18, and 12/25/18. Record review of CR #98's nurses notes dated 1/13/19 at 6:21AM revealed, Resident observed on floor by staff assessment provided noted abrasion on right forehead assisted back to bed vital signs obtained and family and doctor notified at this time will continue monitor resident very agitated and confused will continue to monitor. Record review of CR #98's incident report dated 1/13/19 at 6:15AM revealed he had an unwitnessed fall in his room from bed to the floor. It was noted the resident attempted to get up from the bed without assistance and he was found on the floor by the bed. The resident was assessed, and first aid was applied to abrasion on the front of his head. The resident received in house treatment and was under observation. Medical risk factors possibly related to the incident were listed as fall history, inability to understand directions, confusion/disorientation, incontinency, and sensory limitations. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: safety cues/reinforcement/reminder and pain assessment. Addendum: resident is high risk of fall. Record review of CR #98's nurses notes dated 1/13/19 at 3:27PM revealed, Resident status [REDACTED]. Neuros continue; abrasion noted to R (Right) side forehead with slight discoloration; tx wrote to cleanse with NS, pat dry and apply TAO daily until resolved. Called RP in regard to weekly updates; resident up in wheel chair at this time; spoke with RP; resident became frustrated saying, I don't care, over and over. Resident began to propel self via wheel chair down the hallway; resident made half way down the hall on west wing; writer able to redirect; resident wanted at this time to see the building. Writer propel resident throughout facility; resident asked to go back to bed at this time. Resident up in w/c (Wheel chair ) for 20 minutes; will continue to monitor throughout shift. Record review of CR #98's nurses notes dated 1/14/19 at 5:12AM revealed, Resident s/p fall day 1/3 Abrasion on R forehead. Vital signs are stable. Neuro check is in progress. Will continue to monitor. Record review of CR #98's nurses notes dated 1/14/19 at 9:48AM revealed, Resident s/p fall day1/3. Neuro check in progress. Resident has abrasion on left side of forehead, no bleeding noted. Resident denies pain. Vital signs BP 101/74, pulse 78, respiration 18, Temperature 97.7. Will continue to monitor. Record review of CR #98's nurse notes dated 1/14/19 at 10:42PM revealed, Resident s/p fall day 1/3, abrasion on left side of forehead. Resident was assessed an no infection at site of abrasion. Vital signs are stable. Temperature 98.2. Will continue to monitor. Record review of CR #98's nurse notes dated 1/15/19 at 4:18AM revealed, Resident s/p fall day 2/3, denies pain, has abrasion on left side of forehead, no bleeding noted on this shift. Neuro checks in progress. Vital signs - BP 113/74, pulse 79, respiration 20, temperature 97.8. Will continue to monitor. Record review of CR #98's nurses notes dated 1/15/19 at 9:43AM revealed, Resident s/p fall day 2/3. Neuro check in progress. Abrasion on right side of forehead resolving. No bleeding noted. Resident denied pain. Vital signs BP 102/68, pulse 70, respiration 18, temperature 97.6. Will continue to monitor. Record review of CR#98's record revealed no documentation indicating CR#98 had another fall incident with injury to his left forehead. Record review of CR #98's nurses notes dated 1/15/19 at 11:1158AM revealed, Resident sitting on the floor at bedside. Resident denies pain, any discomfort, has abrasion on right side of forehead from previous fall. Neuro check in progress. No injuries noted on this fall. Resident stated was trying to get up from bed. Bilateral lower/upper extremities PROM intact. With help of CNA was assisted back to bed. Vital signs Bp 104/75, pulse 78, respiration 18, temperature 97.7, O2 97% on room air. NP, RP notified. Will continue to monitor. Record review of CR #98's incident report dated 1/15/19 at 11:45AM revealed he had unwitnessed fall in his room from bed to floor. The resident was observed sitting on the floor at his bedside, he denied pain or any discomfort. He had an abrasion on the right side of his forehead from his previous fall. Neuro checks were in progress. No injuries were noted from the current fall and the resident said he tried to get up from bed. Resident had a head to toe assessment with no noted injuries. Resident was assisted back to bed. Medical risk factors possibly related to the incident were listed as fall history, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall were bed in low position and call light within reach. Further review of post fall assessment revealed no change in interventions from falls on 12/12/18,12/25/18, and 1/13/19. Record review of CR #98's Physical Therapy discharge summary revealed he started services on 1/15/19 through 2/7/19. The clinical reason CR #98 received PT services was for his score for bed mobility and transfers. The summary revealed the resident worked on the ability to stand, to self-propel in wheel chair, bed mobility, transfers, and use of walker. Record review of CR #98's nurse's notes dated 1/17/19 at 6:23AM revealed, Resident on s/p fall with neurological evaluation, abrasion in R forehead is dry with scab, remain agitative at times assisted by staff with all activities of daily living will continue to monitor temp 96.8 respiration 22 pulse 76 BP 107/65. Record review of CR #98's nurses notes dated 1/17/19 at 6:48PM revealed, Resident was observed laying on the floor at bedside. Resident denies pain or any discomfort. No injuries noted on this fall. Though resident has abrasion on right side of the forehead from previous fall. Vital signs are BP 122/75, pulse 77, respiration 18, O2 saturation 90%, temperature 97.7. RP and NP notified. NP gave order for X-ray . Will continue to monitor. Record review of CR #98's incident report dated 1/17/19 at 6:06PM revealed he had an unwitnessed fall in his room. The resident was observed laying on the floor at his bedside, resident was assessed with [REDACTED]. Medical risk factors possibly related to the incident were listed as confusion/disorientation. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall were night light, bed in low position, mechanical lift for transfer, call light within reach, and wheel chair brake extensions with tops painted orange for additional visual cues. Interventions to be implemented to minimize risk of occurrence: lower bed, safety precautions and call light reachable. Further review of post fall assessment revealed no change in interventions from falls on 12/12/18, 12/25/18, 1/13/19 and 1/15/19. Record review of CR #98's NP progress note dated 1/17/19 revealed resident was seen for persistent elevated BUN labs. Further review of notes revealed ongoing abnormalities in previous labs, will adjust treatment as needed. Elevated BUN- ongoing but improving , continue to encourage hydration. Record review of CR #98's nurses notes dated 1/17/19 at 11:48PM revealed, NP was at the facility and cancel X-ray order for the resident. Will continue to monitor. Record review of CR #98's nurses notes dated 1/18/19 at 6:23AM revealed, Resident alert with confusion skin warm and dry attempting to get out from bed, staff assisted resident no signs or symptoms of pain noted. Record review of CR #98's nurses notes dated 1/21/19 at 1:07PM revealed, Resident was found lying on the floor in his room at bedside at 12:35PM. Resident hit his head, swelling in size 2.5cm by 3-inches, bleeding noted on right side of forehead. Resident complained of pain on the site of injury. Writer applied ice to the injured site. Resident denies pain in lower and upper extremities during movement. Vital signs BP 165/85, pulse 64, respiration 21, O2 saturation 96% on room air. Called to 911. At 12:50PM resident was sent to hospital ER via stretcher. NP, RP, ADON notified. Record review of CR #98's incident report dated 1/21/19 at 12:36PM revealed he had an unwitnessed fall in his room from bed to floor. The resident was assessed, and he was found to have a hematoma in size 2.5cm by 3inches on right side of his forehead that was bleeding. Ice was applied and 911 was called. He was transported to hospital ER at 12:50PM. Medical risk factors possibly related to incident were listed as fall history, inability to understand directions, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed: Recommendations and interventions post fall: bed in low position, call light within reach, pain assessment, safety cues/reinforcement/reminder, and anti-skid strips to surface-w/c. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach Further review of post fall assessment revealed no change in interventions from falls on 12/12/18, 12/25/18, 1/13/19 , 1/15/19 and 1/17/19. Record review of CR #98's hospital discharge summary dated 1/21/19 revealed his reason for visit was for fall less than 8 feet. He was diagnosed with [REDACTED]. Record review of CR #98's nurses notes dated 1/21/19 at 1:07PM revealed, Resident came back from hospital at 7:15PM, RP notified. Resident X-ray , electrocardiogram (EKG), and cultures done and UTI found. Resident received a new order [MEDICATION NAME] topical 500 unit/g ointment apply topical 3 times daily for 7days. Keflex 500mg oral 1 cap by mouth 3 times for 7 days. Neuro checks in progress. Will continue to monitor. Record review of CR #98's Interdisciplinary Therapy Data Collection form dated 1/22/19 revealed he was on PT services and was awaiting insurance authorization to initiate treatment. The form also revealed resident was on OT services and was recommended for speech therapy for falls. Record review of Record of in-service form dated 1/23/19 revealed there was a Fall interdisciplinary team (IDT) meeting. Residents with multiple falls and those who had falls in (MONTH) of 2019 plan of care/interventions and the incident/accident reports were reviewed. Notes provided from meeting did not detail what residents were reviewed or what additional interventions resulted from the meeting. Record review of CR #98's NP progress notes dated 1/24/19 revealed he was seen and examined s/p fall to evaluate his skin and musculature, signs and symptoms that may indicate fracture or deep tissue injury. The resident was sent to the hospital after fall he had but was returned to facility the same day. The note revealed CR #98's treatment for [REDACTED]. The resident and his family were advised to call don't fall. His bed to be at low position, call light within reach, environment free from hazards. The Physical therapist was coordinating exercises and rehabilitation. Record review of CR #98's incident report dated 1/31/19 at 7:01PM revealed he was sitting his wheelchair and was noted to be leaned over bending down and fell on his right side before staff were able to reach him. Resident was noted with a small skin tear to nose and right forehead and first aid was applied. The resident was immediately assessed, and his vitals were 124/72, 80, 97.9, 20, 98%. CR #98's nose and his right forehead with skin tear/bruise to right eye area was cleansed with ns, pat dry, TAO, and left open to air. Resident was able to move all extremities and denied pain or discomfort. The MD and RP were notified. Incident further revealed the injuries observed at the time of incident were a bruise and skin tear to the face. Resident was noted to have a [DIAGNOSES REDACTED]. Interview on 2/13/19 at 2:00PM, the Administrator said there was no nurses notes about CR #98's fall on 1/31/19 because the facility was in the process of changing over to a new electronic record system during that time. Record review of CR #98's care plan conference summary dated 1/31/19 revealed therapy services discussed in detail the resident's safety and what was functional for him. The resident was said to be on PT and OT services three times a week and was evaluated by ST, they were awaiting his insurance approval. CR #98's status was discussed in detail with his RP, one to one service was discussed because of the resident's impulsiveness and high risk for repeated falls. The RP was not willing to get one on one care at that time. Interview on 2/15/19 at 4:30PM, the DON said they had a care plan meeting with CR#98's family and the facility suggested one on one supervision to CR#98's RP, but the RP was unable to provide that. Record review of CR #98's Interdisciplinary Therapy Data Collection form dated 2/1/19 revealed he was on PT caseload. The form also revealed OT had anti-slip material placed in his wheel chair to decrease sliding. Resident was pending approval from insurance for speech therapy services. Record review of CR #98's nurses notes dated from 1/21/19 through 2/3/19 indicated treatment and improvement of an abrasion on the right side of his forehead. Record review of CR #98's nurses notes dated 2/5/19 at 4:15AM revealed, At 4:00AM: Resident was found on the floor and was noted with a bump on the left side of his forehead no active bleeding was noted. Resident denied pain at this time. Resident was helped back in bed. Neuro checks was initiated. Resident continues attempting to get out from the bed. Bed is still in low position. NP was notified, order received for X-ray of the skull. RP was called, but no response, will follow up in the AM. Vital sign B/P 127/66, pulse 70, Resp 18, Temp 97.8. Note was written by RN #10. Record review of CR #98's incident report dated 2/5/19 at 5:51AM revealed an incident description stating, Resident was noted on the floor on his left side. Resident attempted to get up from the bed without assistance. Resident had been noted in bed less than 15 minutes prior to fall resting. Resident was immediately assessed per nurse, hematoma was noted on left forehead. Vital signs were taken with no abnormalities noted; able to move extremities without difficulty; resident was assisted back in bed per staff and neuro check were initiated - within normal limits at this time. Injuries observed at the time of the incident were a hematoma/bump on the left side of head. Report was completed by RN #10. Record review of CR #98's post fall assessment dated [DATE] revealed: - Date and time of event: 2/5/19 at 4:00AM - Activity at time of fall: bed to floor<b (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of 28 residents (CR#98) reviewed for accidents and hazards, in that: CR#98 who was cognitively impaired and with a known fall history , sustained multiple falls with head injuries and was not provided effective individualized interventions to prevent recurring falls. CR#98 was identified to require one on one supervision and monitoring which was not provided. CR#98 had a fall with head injury on 2/5/19 and had a change in condition three days after which was not identified for prompt intervention . CR#98 was found unresponsive the following morning and transferred to the hospital where he was diagnosed with [REDACTED]. On 2/15/2019, an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on 2/20/2019, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected one closed record who remained in the hospital ICU . Findings included: CR #98 Record review of CR #98's face sheet revealed a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #98's nurses notes dated 11/9/18 at 10:20PM revealed, admitted to the facility from hospital; Diagnoses: [REDACTED]. Alert and oriented X 1; notified family of resident's arrival; [MEDICATION NAME] and [MEDICATION NAME] consents filed. Will continue to monitor; bed lowered to lowest position. Resident noted to [MEDICAL CONDITION]; minimal discoloration noted to chest area. Record review of CR #98's NP initial visit notes dated 11/10/18 revealed in part, Patient is seen and examined to evaluate nurses concerns about generalized weakness, difficulty walking upon admission. Patient was admitted to hospital for heat stroke. During the course of this hospitalization , patient was managed for acute [MEDICAL CONDITION], weakness, [MEDICAL CONDITION]. Patient has a medical history of [REDACTED]. Further review of the note revealed in part, patient is at risk of falling, medications is reviewed frequently, nursing staff is asses (SIC) and adjusting care as needed to accommodate the fall risks. The NP noted the treatment plan for CR #98's [MEDICAL CONDITION] was for him to be evaluated and treated by PT if he had new onset of decrease in strength, decline in physical and functional mobility, reduced ability to safely ambulate and transfer, and increased need for assistance with ADL's. The note reflected the treatment plan for generalized weakness was for OT to evaluate and treat CR #98 to improve his ADL's and functional status. Record review of CR #98's Admission Minimum Data Set ((MDS) dated [DATE] revealed CR#98 was severely impaired for cognitive skills and had short- and long-term memory problems. The MDS revealed CR #98 had fluctuating episodes of disorganized thinking and had behavioral symptoms not directed towards others which occurred 1 to 3 days. The MDS revealed CR#98's behavioral symptoms placed him at risk for physical illness or injury. The MDS revealed CR #98 required total dependence with two persons physical assist for transfer, locomotion on unit and locomotion off unit. CR #98 was unsteady, only able to stabilize with staff assistance, walking activity did not occur, and he was unsteady for surface - to - surface transfer. CR#98 used mobility device - wheel chair. Further review of MDS revealed the resident had a fall with injury that was not major . Record review of CR #98's undated Care Plan revealed, in part; Focus: I am at increased risk for falls related to (r/t) decreased safety awareness, impulsivity, and Poor communication/comprehension. 11/15/18 fall with abrasion to forehead. 12/12/18 fall no injury. 12/25/18 fall no injury. 1/6/19 fall continue Occupational Therapy (OT) services. 1/13/19 fall with abrasion to forehead. 1/15/19 fall no injury. 1/17/19 fall no injury. 1/21/19 fall sent to emergency room (ER). 1/31/19 fall no injury. 2/5/19 fall no injury. Goal: I will not sustain serious injury r/t a fall through the review date. Intervention/Tasks: 11/15/18 scoop mattress for safety 12/12/18 high back w/c 12/25/18 OT to evaluate and treat. 1/6/19 PT/ ST screen. 1/13/19 Physical Therapy (PT)/ OT screen, PT to treat. 1/15/19 Labs. 1/17/19 PT/ OT/ Speech therapy (ST) screen. 1/21/19 antibiotic therapy (ABT) for urinary tract infection [MEDICAL CONDITION]. 1/31/19- anti-slip sheet to wheel chair (w/c). Anticipate and meet the resident's needs Assist me with routine and as needed toileting Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Drug regimen review performed. Keep bed in low position. PT evaluate and treat as ordered or as needed (PRN). Focus: I have an ADL self-care performance deficit r/t cognitive impairment. Goal: My needs will be met through review date. Intervention/Tasks: I use a w/c for mobility. I am dependent on propulsion. Bed Mobility: one-person physical assist. Toilet Use: The resident is totally dependent on one staff for toilet use. Transfer: the resident is able to assist with transfer. One person assists. PT/OT evaluation and treatment as per doctor (MD) orders. Focus: I have behavioral issues r/t impulsivity and pulling at enteral feed tube. Goal: I will not have unidentified complications r/t my behaviors through the review date. Intervention/Tasks: Administer medication as ordered. Monitor/document for side effects and effectiveness. Explain all procedures to the resident and allow the resident to adjust to changes. If reasonable, discuss behavior. Explain/reinforce why behavior can increase risk for fall/interruption of feed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations. Document behavior and potential causes . Record review of CR #98's Occupational Therapy Discharge Summary revealed he started services on 11/13/18 and was discharged from services on 11/26/18. The summary revealed CR #98's clinical reasoning for OT services was to increase sitting balance during ADL's and to be fitted for wheel chair to spend time out of bed. Record review of CR #98's NP progress notes dated 11/15/18 revealed he was evaluated for acute on chronic disease management and tolerance with increased physical activity. Further review of the note revealed in part, Patient is seen, examined and his progress in therapy need reviewed. Patients medical history is also being evaluated to promote full participation in therapy. Patient is showing some progress in therapy per therapist report. Patient is stable, no reports of nausea, vomiting, headache. The note reflected treatment for [REDACTED]. Record review of CR #98's nurse's notes dated 11/15/18 at 6:05PM revealed, Resident is alert oriented x2, with confusions, had unwitnessed fall at 5:00PM. He was observed on the floor by the bedside lying on his back, sustained a skin opening on the right side of his forehead and is bleeding. Vital signs Blood Pressure (BP) 118/81, Pulse 87, Respiration 19, Temperature 99.3, and O2 Saturation 97% on room air. Nurse Practitioner (NP) was notified who ordered to send the resident to the emergency room (ER) for further evaluation and management. Record review of CR #98's incident report dated 11/15/18 at 5:49PM revealed resident had an unwitnessed fall in his room. Report narrative revealed the resident was alert and oriented x2 and had confusion. He had an unwitnessed fall at 5:00PM where he was observed on the floor at his bedside lying on his back. He sustained a skin opening on the right side of his forehead and is bleeding. NP was notified who ordered to send the resident out to the ER for further evaluation and management. The resident had an abrades area with bleeding to the right side of the forehead, there was no hematoma noted. Listed medical risk factors related to the incident included: fall history, inability to understand directions, substance abuse, confusion/disorientation, incontinency, sensory limitations, and tremors/[MEDICAL CONDITION]. Record review of CR #98's hospital after visit summary dated 11/15/18 revealed the reason for visit was for a fall. He was diagnosed with [REDACTED]. Instructions were to follow up with his primary care provider, Tylenol as needed, clean wound twice a day, and to return to ER for any further problems or concerns. Record review of CR #98's nurse's notes dated 11/16/18 at 12:12AM revealed, Resident returned from the hospital ER at 12:00AM with the [DIAGNOSES REDACTED]. Abrasion of scalp was clean, and [MEDICATION NAME] was applied. Resident was given [MEDICATION NAME] while in the ER. NP was notified. Resident in bed, bed in low position and call light within reach. BP 126/78, Pulse 84, Respiration 18, Temperature 97.8. Resident remains stable at this time with no distress noted. Will continue with plan of care. Record review of CR #98's NP progress notes dated 11/16/18 revealed she saw and examined the resident at his bedside per the nurses report of abrasion to forehead. The treatment listed for the abrasion was to cleanse abrasion to forehead with NS (Normal saline), pad dry, apply TAO (triple antibiotic ointment) and dressing. Record review of CR #98's NP progress notes dated 11/19/18 revealed he was evaluated for acute on chronic disease management and tolerance with increased physical activity. Further review of the note revealed in part, Patient is seen, examined and his progress in therapy need reviewed. Patients medical and physical condition is also being evaluated to promote full participation in therapy. Patient is showing some progress in therapy per therapist report. Patient is stable, no reports of nausea, vomiting, headache. The note reflected treatment for [REDACTED]. Record review of CR #98's NP progress notes from 11/23/18 to 12/10/18 revealed ongoing evaluation of current treatment for [REDACTED]. Record review of CR #98's records revealed the resident was discharged from OT on 11/26/18. OT was re-started on 1/2/19. Record review of CR #98's nurse's notes dated 12/12/18 at 12:43PM revealed, writer found resident lying on the floor by his bed. No injuries noted. No pain in extremities noted during movement. Bed was in low position. Resident denies pain. Neuro-check in progress. Vital signs BP 107/64, pulse 67, Respiration 20, Temperature 97.9. NP and Responsible party (RP) notified. Will continue to monitor. Record review of CR #98's incident report dated 12/12/18 at 12:01PM revealed the resident had an unwitnessed fall in his room where he fell from bed to floor. The resident was observed lying on the floor on the side of his bed. Head to toe assessment was done with no noted injuries. There was no pain in extremities noted during movement. The bed was in low position and the resident denied pain, neuro-checks were in progress. Listed medical risk factors related to the incident included: fall history, inability to understand directions, incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: night light, bed in low position, physical therapy, call light within reach, psych evaluation, and pain assessment. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach. Record review of CR #98's NP progress notes dated 12/14/18 revealed no change in treatment or fall interventions. Record review of CR #98's nurses notes dated 12/18/19 at 10:22AM revealed, Resident was getting up to wheel chair during this shift. Resident was trying to get up by self from wheel chair while was sitting at nursing station. When writer was trying to redirect resident, he screamed get out of me, do not touch me. Writer asked is resident wants to go back to bed, he agreed. Resident resting in a bed at this time, with no distress noted. Vital signs stable. Will continue to monitor. Record review of CR #98's nurses notes dated 12/19/18 at 1:34PM revealed, Resident was up to w/c this morning. Resident was trying to get up, redirected by writer with success. Resident was sitting in wheel chair for 40 minutes. The writer asked if resident wants to go to bed, resident agreed. No distress, no pain noted. Will continue with plan of care. Record review of CR #98's nurses notes dated 12/25/18 at 8:45AM revealed, Writer observed resident lying on the floor at bedside. No injuries noted, no pain in extremities during movement noted. Bed was in low position. Resident denies any pain, discomfort. Neuro check in progress. Vital signs BP 149/75, pulse 71, Respiration 20, Temperature 97.9. NP and RP notified. Will continue to monitor. Record review of CR #98's incident report dated 12/25/18 at 8:45AM revealed he had an unwitnessed fall in his bed where he fell from his bed to the floor. Resident was observed on the floor in his room at his bedside. He denied pain and discomfort. His vitals were BP 149/75, pulse 71, Respiration 20, and Temperature 97.9. There was no pain noted during movement of his extremities. No injuries were noted. Medical risk factors possibly related to incident were listed as, fall history, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: bed in low position, call light within reach, and pain assessment. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach. Further review of post fall assessment revealed no change in interventions. Record review of CR #98's Occupational Therapy Discharge Summary revealed he started services on 1/2/19 through 2/4/19. The summary revealed CR #98 clinical reasoning for OT services was for his ADL scores and clinical judgement. Record review of CR #98's nurses notes dated 1/6/19 at 6:50PM revealed, 1/6/19 at 6:00PM, patient noted quickly sliding from low bed, confused conversation per usual, denies pain, stated was trying to get to other bed and that it looks comfortable. Bilateral lower/upper extremities passive range of motion (PROM) intact, no apparent injuries noted. Assist back to bed with two persons assist. Vital signs: temperature 97.6, Pulse 64, respirations 19, BP 11/54, O2 (Oxygen) turation 97%. NP updated, to monitor, RP updated, ADON updated, will continue to monitor. No acute distress noted. Low bed maintained, warm blanket provided per request for comfortable bed. Record review of CR #98's nurses notes dated 1/6/19 at 6:30PM revealed he had an unwitnessed fall in his room from his bed to the floor. While nurse was passing the residents room he noted the CR #98 sliding from bed to lie on his right side, bed was in low position and he stated he wanted to get to the other bed. He was assessed with [REDACTED]. Record review of CR #98's post fall assessment dated [DATE] revealed prior to the fall, resident was doing usual activities, reaching down, and had tremors. Recommendations and interventions post fall: bed in low position, physical therapy, call light within reach, assistive device within reach, pain assessment, and keep warm blanket on. Interventions to be implemented to minimize risk of occurrence: offer warm blanket for comfort to keep warm Further review of post fall assessment revealed no change in interventions from falls on 12/12/18, and 12/25/18. Record review of CR #98's nurses notes dated 1/13/19 at 6:21AM revealed, Resident observed on floor by staff assessment provided noted abrasion on right forehead assisted back to bed vital signs obtained and family and doctor notified at this time will continue monitor resident very agitated and confused will continue to monitor. Record review of CR #98's incident report dated 1/13/19 at 6:15AM revealed he had an unwitnessed fall in his room from bed to the floor. It was noted the resident attempted to get up from the bed without assistance and he was found on the floor by the bed. The resident was assessed, and first aid was applied to abrasion on the front of his head. The resident received in house treatment and was under observation. Medical risk factors possibly related to the incident were listed as fall history, inability to understand directions, confusion/disorientation, incontinency, and sensory limitations. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: safety cues/reinforcement/reminder and pain assessment. Addendum: resident is high risk of fall. Record review of CR #98's nurses notes dated 1/13/19 at 3:27PM revealed, Resident status [REDACTED]. Neuros continue; abrasion noted to R (Right) side forehead with slight discoloration; tx wrote to cleanse with NS, pat dry and apply TAO daily until resolved. Called RP in regard to weekly updates; resident up in wheel chair at this time; spoke with RP; resident became frustrated saying, I don't care, over and over. Resident began to propel self via wheel chair down the hallway; resident made half way down the hall on west wing; writer able to redirect; resident wanted at this time to see the building. Writer propel resident throughout facility; resident asked to go back to bed at this time. Resident up in w/c (Wheel chair ) for 20 minutes; will continue to monitor throughout shift. Record review of CR #98's nurses notes dated 1/14/19 at 5:12AM revealed, Resident s/p fall day 1/3 Abrasion on R forehead. Vital signs are stable. Neuro check is in progress. Will continue to monitor. Record review of CR #98's nurses notes dated 1/14/19 at 9:48AM revealed, Resident s/p fall day1/3. Neuro check in progress. Resident has abrasion on left side of forehead, no bleeding noted. Resident denies pain. Vital signs BP 101/74, pulse 78, respiration 18, Temperature 97.7. Will continue to monitor. Record review of CR #98's nurse notes dated 1/14/19 at 10:42PM revealed, Resident s/p fall day 1/3, abrasion on left side of forehead. Resident was assessed an no infection at site of abrasion. Vital signs are stable. Temperature 98.2. Will continue to monitor. Record review of CR #98's nurse notes dated 1/15/19 at 4:18AM revealed, Resident s/p fall day 2/3, denies pain, has abrasion on left side of forehead, no bleeding noted on this shift. Neuro checks in progress. Vital signs - BP 113/74, pulse 79, respiration 20, temperature 97.8. Will continue to monitor. Record review of CR #98's nurses notes dated 1/15/19 at 9:43AM revealed, Resident s/p fall day 2/3. Neuro check in progress. Abrasion on right side of forehead resolving. No bleeding noted. Resident denied pain. Vital signs BP 102/68, pulse 70, respiration 18, temperature 97.6. Will continue to monitor. Record review of CR#98's record revealed no documentation indicating CR#98 had another fall incident with injury to his left forehead. Record review of CR #98's nurses notes dated 1/15/19 at 11:1158AM revealed, Resident sitting on the floor at bedside. Resident denies pain, any discomfort, has abrasion on right side of forehead from previous fall. Neuro check in progress. No injuries noted on this fall. Resident stated was trying to get up from bed. Bilateral lower/upper extremities PROM intact. With help of CNA was assisted back to bed. Vital signs Bp 104/75, pulse 78, respiration 18, temperature 97.7, O2 97% on room air. NP, RP notified. Will continue to monitor. Record review of CR #98's incident report dated 1/15/19 at 11:45AM revealed he had unwitnessed fall in his room from bed to floor. The resident was observed sitting on the floor at his bedside, he denied pain or any discomfort. He had an abrasion on the right side of his forehead from his previous fall. Neuro checks were in progress. No injuries were noted from the current fall and the resident said he tried to get up from bed. Resident had a head to toe assessment with no noted injuries. Resident was assisted back to bed. Medical risk factors possibly related to the incident were listed as fall history, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall were bed in low position and call light within reach. Further review of post fall assessment revealed no change in interventions from falls on 12/12/18,12/25/18, and 1/13/19. Record review of CR #98's Physical Therapy discharge summary revealed he started services on 1/15/19 through 2/7/19. The clinical reason CR #98 received PT services was for his score for bed mobility and transfers. The summary revealed the resident worked on the ability to stand, to self-propel in wheel chair, bed mobility, transfers, and use of walker. Record review of CR #98's nurse's notes dated 1/17/19 at 6:23AM revealed, Resident on s/p fall with neurological evaluation, abrasion in R forehead is dry with scab, remain agitative at times assisted by staff with all activities of daily living will continue to monitor temp 96.8 respiration 22 pulse 76 BP 107/65. Record review of CR #98's nurses notes dated 1/17/19 at 6:48PM revealed, Resident was observed laying on the floor at bedside. Resident denies pain or any discomfort. No injuries noted on this fall. Though resident has abrasion on right side of the forehead from previous fall. Vital signs are BP 122/75, pulse 77, respiration 18, O2 saturation 90%, temperature 97.7. RP and NP notified. NP gave order for X-ray . Will continue to monitor. Record review of CR #98's incident report dated 1/17/19 at 6:06PM revealed he had an unwitnessed fall in his room. The resident was observed laying on the floor at his bedside, resident was assessed with [REDACTED]. Medical risk factors possibly related to the incident were listed as confusion/disorientation. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall were night light, bed in low position, mechanical lift for transfer, call light within reach, and wheel chair brake extensions with tops painted orange for additional visual cues. Interventions to be implemented to minimize risk of occurrence: lower bed, safety precautions and call light reachable. Further review of post fall assessment revealed no change in interventions from falls on 12/12/18, 12/25/18, 1/13/19 and 1/15/19. Record review of CR #98's NP progress note dated 1/17/19 revealed resident was seen for persistent elevated BUN labs. Further review of notes revealed ongoing abnormalities in previous labs, will adjust treatment as needed. Elevated BUN- ongoing but improving , continue to encourage hydration. Record review of CR #98's nurses notes dated 1/17/19 at 11:48PM revealed, NP was at the facility and cancel X-ray order for the resident. Will continue to monitor. Record review of CR #98's nurses notes dated 1/18/19 at 6:23AM revealed, Resident alert with confusion skin warm and dry attempting to get out from bed, staff assisted resident no signs or symptoms of pain noted. Record review of CR #98's nurses notes dated 1/21/19 at 1:07PM revealed, Resident was found lying on the floor in his room at bedside at 12:35PM. Resident hit his head, swelling in size 2.5cm by 3-inches, bleeding noted on right side of forehead. Resident complained of pain on the site of injury. Writer applied ice to the injured site. Resident denies pain in lower and upper extremities during movement. Vital signs BP 165/85, pulse 64, respiration 21, O2 saturation 96% on room air. Called to 911. At 12:50PM resident was sent to hospital ER via stretcher. NP, RP, ADON notified. Record review of CR #98's incident report dated 1/21/19 at 12:36PM revealed he had an unwitnessed fall in his room from bed to floor. The resident was assessed, and he was found to have a hematoma in size 2.5cm by 3inches on right side of his forehead that was bleeding. Ice was applied and 911 was called. He was transported to hospital ER at 12:50PM. Medical risk factors possibly related to incident were listed as fall history, inability to understand directions, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed: Recommendations and interventions post fall: bed in low position, call light within reach, pain assessment, safety cues/reinforcement/reminder, and anti-skid strips to surface-w/c. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach Further review of post fall assessment revealed no change in interventions from falls on 12/12/18, 12/25/18, 1/13/19 , 1/15/19 and 1/17/19. Record review of CR #98's hospital discharge summary dated 1/21/19 revealed his reason for visit was for fall less than 8 feet. He was diagnosed with [REDACTED]. Record review of CR #98's nurses notes dated 1/21/19 at 1:07PM revealed, Resident came back from hospital at 7:15PM, RP notified. Resident X-ray , electrocardiogram (EKG), and cultures done and UTI found. Resident received a new order [MEDICATION NAME] topical 500 unit/g ointment apply topical 3 times daily for 7days. Keflex 500mg oral 1 cap by mouth 3 times for 7 days. Neuro checks in progress. Will continue to monitor. Record review of CR #98's Interdisciplinary Therapy Data Collection form dated 1/22/19 revealed he was on PT services and was awaiting insurance authorization to initiate treatment. The form also revealed resident was on OT services and was recommended for speech therapy for falls. Record review of Record of in-service form dated 1/23/19 revealed there was a Fall interdisciplinary team (IDT) meeting. Residents with multiple falls and those who had falls in (MONTH) of 2019 plan of care/interventions and the incident/accident reports were reviewed. Notes provided from meeting did not detail what residents were reviewed or what additional interventions resulted from the meeting. Record review of CR #98's NP progress notes dated 1/24/19 revealed he was seen and examined s/p fall to evaluate his skin and musculature, signs and symptoms that may indicate fracture or deep tissue injury. The resident was sent to the hospital after fall he had but was returned to facility the same day. The note revealed CR #98's treatment for [REDACTED]. The resident and his family were advised to call don't fall. His bed to be at low position, call light within reach, environment free from hazards. The Physical therapist was coordinating exercises and rehabilitation. Record review of CR #98's incident report dated 1/31/19 at 7:01PM revealed he was sitting his wheelchair and was noted to be leaned over bending down and fell on his right side before staff were able to reach him. Resident was noted with a small skin tear to nose and right forehead and first aid was applied. The resident was immediately assessed, and his vitals were 124/72, 80, 97.9, 20, 98%. CR #98's nose and his right forehead with skin tear/bruise to right eye area was cleansed with ns, pat dry, TAO, and left open to air. Resident was able to move all extremities and denied pain or discomfort. The MD and RP were notified. Incident further revealed the injuries observed at the time of incident were a bruise and skin tear to the face. Resident was noted to have a [DIAGNOSES REDACTED]. Interview on 2/13/19 at 2:00PM, the Administrator said there was no nurses notes about CR #98's fall on 1/31/19 because the facility was in the process of changing over to a new electronic record system during that time. Record review of CR #98's care plan conference summary dated 1/31/19 revealed therapy services discussed in detail the resident's safety and what was functional for him. The resident was said to be on PT and OT services three times a week and was evaluated by ST, they were awaiting his insurance approval. CR #98's status was discussed in detail with his RP, one to one service was discussed because of the resident's impulsiveness and high risk for repeated falls. The RP was not willing to get one on one care at that time. Interview on 2/15/19 at 4:30PM, the DON said they had a care plan meeting with CR#98's family and the facility suggested one on one supervision to CR#98's RP, but the RP was unable to provide that. Record review of CR #98's Interdisciplinary Therapy Data Collection form dated 2/1/19 revealed he was on PT caseload. The form also revealed OT had anti-slip material placed in his wheel chair to decrease sliding. Resident was pending approval from insurance for speech therapy services. Record review of CR #98's nurses notes dated from 1/21/19 through 2/3/19 indicated treatment and improvement of an abrasion on the right side of his forehead. Record review of CR #98's nurses notes dated 2/5/19 at 4:15AM revealed, At 4:00AM: Resident was found on the floor and was noted with a bump on the left side of his forehead no active bleeding was noted. Resident denied pain at this time. Resident was helped back in bed. Neuro checks was initiated. Resident continues attempting to get out from the bed. Bed is still in low position. NP was notified, order received for X-ray of the skull. RP was called, but no response, will follow up in the AM. Vital sign B/P 127/66, pulse 70, Resp 18, Temp 97.8. Note was written by RN #10. Record review of CR #98's incident report dated 2/5/19 at 5:51AM revealed an incident description stating, Resident was noted on the floor on his left side. Resident attempted to get up from the bed without assistance. Resident had been noted in bed less than 15 minutes prior to fall resting. Resident was immediately assessed per nurse, hematoma was noted on left forehead. Vital signs were taken with no abnormalities noted; able to move extremities without difficulty; resident was assisted back in bed per staff and neuro check were initiated - within normal limits at this time. Injuries observed at the time of the incident were a hematoma/bump on the left side of head. Report was completed by RN #10. Record review of CR #98's post fall assessment dated [DATE] revealed: - Date and time of event: 2/5/19 at 4:00AM - Activity at time of fall: bed (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including state agency for one of 28 residents (CR #98) reviewed for neglect, in that ; CR#98 who was cognitively impaired sustained 4 unwitnessed falls with head injuries which were not reported to HHSC. This failure to report falls resulted in HHSC not investigating all falls for intervention to prevent subsequent falls and injuries. These failures affected one closed record and placed him at risk for abuse and neglect. Findings included: CR #98 Record review of CR #98's face sheet revealed a [AGE] year-old male admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #98's nurses notes dated 11/9/18 at 10:20PM revealed, admitted to the facility from hospital; Diagnoses: [REDACTED]. Resident is 55, male, Caucasian, arrived approximately 8:30PM via Emergency Medical Services (EMS) stretcher under medical direction of her Physician. No known allergies [REDACTED]. [MEDICAL CONDITION] (TB) administered to left forearm. Resident currently on [MEDICATION NAME] 1.5 at 60mL/hour; resident is allowed pleasure feedings. Alert and oriented X 1; notified family of resident's arrival; [MEDICATION NAME] and [MEDICATION NAME] consents filed. Will continue to monitor; bed lowered to lowest position. Resident noted to [MEDICAL CONDITION]; minimal discoloration noted to chest area. Record review of CR #98's NP initial visit notes dated 11/10/18 revealed in part, Patient is seen and examined to evaluate nurses concerns about generalized weakness, difficulty walking upon admission. Patient was admitted in this hospital for heat stroke. During the course of this hospitalization , patient was managed for acute [MEDICAL CONDITION], weakness, [MEDICAL CONDITION], [DIAGNOSES REDACTED], hyper-[MEDICAL CONDITIONS] ([MEDICAL CONDITION]), right pleural infusion. Patient has a medical history of [REDACTED]. Further review of the note revealed in part, patient is at risk of falling, medications is reviewed frequently, nursing staff is asses (SIC) and adjusting care as needed to accommodate the fall risks . The NP noted the treatment plan for CR #98's [MEDICAL CONDITION] was for him to be evaluated and treated by PT if he had new onset of decrease in strength, decline in physical and functional mobility, reduced ability to safely ambulate and transfer, and increased need for assistance with ADL's. The note reflected the treatment plan for generalized weakness was for OT to evaluate and treat CR #98 to improve his ADL's and functional status. Record review of CR #98's Admission Minimum Data Set ((MDS) dated [DATE] revealed CR#98 was severely impaired for cognitive skills and had short- and long-term memory problems. The MDS revealed CR #98 had fluctuating episodes of disorganized thinking and had behavioral symptoms not directed towards others which occurred 1 to 3 days. The MDS revealed CR#98's behavioral symptoms placed him at risk for physical illness or injury. The MDS revealed CR #98 required total dependence with two persons physical assist for transfer, locomotion on unit and locomotion off unit. CR #98 was unsteady, only able to stabilize with staff assistance, walking activity did not occur, and he was unsteady for surface - to - surface transfer. CR#98 used mobility device - wheel chair. Further review of MDS revealed the resident had a fall with injury that was not major . Record review of CR #98's undated Care Plan revealed, in part; Focus: I am at increased risk for falls related to (r/t) decreased safety awareness, impulsivity, and Poor communication/comprehension. 11/15/18 fall with abrasion to forehead. 12/12/18 fall no injury. 12/25/18 fall no injury. 1/6/19 fall continue Occupational Therapy (OT) services. 1/13/19 fall with abrasion to forehead. 1/15/19 fall no injury. 1/17/19 fall no injury. 1/21/19 fall sent to emergency room (ER). 1/31/19 fall no injury. 2/5/19 fall no injury. Goal: I will not sustain serious injury r/t a fall through the review date. Intervention/Tasks: 11/15/18 scoop mattress for safety 12/12/18 high back w/c 12/25/18 OT to evaluate and treat. 1/6/19 PT/ ST screen. 1/13/19 Physical Therapy (PT)/ OT screen, PT to treat. 1/15/19 Labs. 1/17/19 PT/ OT/ Speech therapy (ST) screen. 1/21/19 antibiotic therapy (ABT) for urinary tract infection [MEDICAL CONDITION]. 1/31/19- anti-slip sheet to wheel chair (w/c). Anticipate and meet the resident's needs Assist me with routine and as needed toileting Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Drug regimen review performed. Keep bed in low position. PT evaluate and treat as ordered or as needed (PRN). Focus: I have an ADL self-care performance deficit r/t cognitive impairment. Goal: My needs will be met through review date. Intervention/Tasks: I use a w/c for mobility. I am dependent on propulsion. Bed Mobility: one-person physical assist. Toilet Use: The resident is totally dependent on one staff for toilet use. Transfer: the resident is able to assist with transfer. One person assists. PT/OT evaluation and treatment as per Doctor (MD) orders. Focus: I have behavioral issues r/t impulsivity and pulling at enteral feed tube. Goal: I will not have unidentified complications r/t my behaviors through the review date. Intervention/Tasks: Administer medication as ordered. Monitor/document for side effects and effectiveness. Explain all procedures to the resident and allow the resident to adjust to changes. If reasonable, discuss behavior. Explain/reinforce why behavior can increase risk for fall/interruption of feed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations. Document behavior and potential causes . Record review of CR #98's Occupational Therapy Discharge Summary revealed CR#98 started services on 11/13/18 and was discharged from services on 11/26/18 because he achieved his highest practical level . The summary revealed CR #98's clinical reasoning for OT services was to increase sitting balance during ADL's and to be fitted for wheel chair to spend time out of bed. Record review of CR #98's nurse's notes dated 11/15/18 at 6:05PM revealed, Resident is alert oriented x2, with confusions, had unwitnessed fall at 5:00PM. He was observed on the floor by the bedside lying on his back, sustained a skin opening on the right side of his forehead and is bleeding. Vital signs Blood Pressure (BP) 118/81, Pulse 87, Respiration 19, Temperature 99.3, and O2 Saturation 97% on room air. Nurse Practitioner (NP) was notified who ordered to send the resident to the emergency room (ER) for further evaluation and management. Record review of CR #98's incident report dated 11/15/18 at 5:49PM revealed resident had an unwitnessed fall in his room. Report narrative revealed the resident was alert and oriented x2 and had confusion. He had an unwitnessed fall at 5:00PM where he was observed on the floor at his bedside lying on his back. He sustained a skin opening on the right side of his forehead and is bleeding. NP was notified who ordered to send the resident out to the ER for further evaluation and management. The resident had an abrased (SIC) area with bleeding to the right side of the forehead, there was no hematoma noted. Listed medical risk factors related to the incident included: fall history, inability to understand directions, substance abuse, confusion/disorientation, incontinency, sensory limitations, and tremors/[MEDICAL CONDITION]. Incident report was not signed and not dated. Record review of CR #98's hospital after visit summary dated 11/15/18 revealed the reason for visit was for a fall. He was diagnosed with [REDACTED]. Instructions were to follow up with his primary care provider, Tylenol as needed, clean wound twice a day, and to return to ER for any further problems or concerns. Record review of CR #98's nurse's notes dated 11/16/18 at 12:12AM revealed, Resident returned from the hospital ER at 12:00AM with the [DIAGNOSES REDACTED]. Abrasion of scalp was clean, and [MEDICATION NAME] was applied. Resident was given [MEDICATION NAME] while in the ER. NP was notified. Resident in bed, bed in low position and call light within reach. BP 126/78, Pulse 84, Respiration 18, Temperature 97.8. Resident remains stable at this time with no distress noted. Will continue with plan of care. Record review of CR #98's nurses notes dated 1/13/19 at 6:21AM revealed, Resident observed on floor by staff assessment provided noted abrasion on right forehead assisted back to bed vital signs obtained and family and doctor notified at this time will continue monitor resident very agitated and confused will continue to monitor. Record review of CR #98's incident report dated 1/13/19 at 6:15AM revealed he had an unwitnessed fall in his room from bed to the floor. It was noted the resident attempted to get up from the bed without assistance and he was found on the floor by the bed. The resident was assessed, and first aid was applied to abrasion on the front of his head. The resident received in house treatment and was under observation. Medical risk factors possibly related to the incident were listed as fall history, inability to understand directions, confusion/disorientation, incontinency, and sensory limitations. Record review of CR #98's post fall assessment dated [DATE] revealed recommendations and interventions post fall: safety cues/reinforcement/reminder and pain assessment. Addendum: resident is high risk of fall Record review of CR #98's nurses notes dated 1/13/19 at 3:27PM revealed, Resident status [REDACTED]. Neuros continue; abrasion noted to R (Right) side forehead with slight discoloration; tx wrote to cleanse with NS, pad dry and apply TAO daily until resolved. Called RP in regard to weekly updates; resident up in wheel chair at this time; spoke with RP; resident became frustrated saying, I don't care, over and over. Resident began to propel self via wheel chair down the hallway; resident made half way down the hall on west wing; writer able to redirect; resident wanted at this time to see the building. Writer propel resident throughout facility; resident asked to go back to bed at this time. Resident up in w/c (Wheel chair ) for 20 minutes; will continue to monitor throughout shift. Record review of CR #98's nurses notes dated 1/21/19 at 1:07PM revealed, Resident was found lying on the floor in his room at bedside a 12:35PM. Resident hit his head, swelling in size 2.5cm by 3-inches, bleeding noted on right side of forehead. Resident complained of pain on the site of injury. Writer applied ice to the injured sire. Resident denies pain in lower and upper extremities during movement. Vital signs BP 165/85, pulse 64, respiration 21, O2 saturation 96% on room air. Called to 911. At 12:50PM resident was sent to hospital ER via stretcher. NP, RP, ADON notified. Record review of CR #98's incident report dated1/21/19 at 12:36PM revealed he had an unwitnessed fall in his room from bed to floor. The resident was assessed, and he was found to have a hematoma in size 2.5cm by 3 inches on right side of his forehead that was bleeding. Ice was applied and 911 was called. He was transported to hospital ER at 12:50PM. Medical risk factors possibly related to incident were listed as fall history, inability to understand directions, confusion/disorientation, and incontinency. Record review of CR #98's post fall assessment dated [DATE] revealed: Recommendations and interventions post fall: bed in low position, call light within reach, pain assessment, safety cues/reinforcement/reminder, and anti-skid strips to surface. Interventions to be implemented to minimize risk of occurrence: bed in low position, call light within reach Record review of CR #98's hospital discharge summary dated 1/21/19 revealed his reason for visit was for fall less than 8 feet. He was diagnosed with [REDACTED]. Record review of CR #98's nurses notes dated 1/21/19 at 1:07PM revealed, Resident came back from hospital at 7:15PM, RP notified. Resident X-ray , electrocardiogram (EKG), and cultures done and UTI found. Resident received a new order [MEDICATION NAME] topical 500 unit/g ointment apply topical 3 times daily for 7days. Keflex 500mg oral 1 cap by mouth 3 times for 7 days. Neuro checks in progress. Will continue to monitor. Record review of CR #98's incident report dated 1/31/19 at 7:01PM revealed he was sitting his wheelchair and was noted to be leaned over bending down and fell on his right side before staff were able to reach him. Resident was noted with a small skin tear to nose and right forehead and first aid was applied. The resident was immediately assessed, and his vitals were 124/72, 80, 97.9, 20, 98%. CR #98's nose and his right forehead with skin tear/bruise to right eye area was cleansed with ns, pat dry, TAO, and left open to air. Resident was able to move all extremities and denied pain or discomfort. The MD and RP were notified. Incident further revealed the injuries observed at the time of incident were a bruise and skin tear to the face. Resident was noted to have a [DIAGNOSES REDACTED]. Interview on 2/13/19 at 2:00PM, the Administrator said there was no nurses notes about CR #98's fall on 1/31/19 because the facility was in the process of changing over to a new electronic record system during that time. Record review of CR #98's nurses notes dated 2/5/19 at 4:15AM revealed, At 4:00AM: Resident was found on the floor and was noted with a bump on the left side of his forehead no active bleeding was noted. Resident denied pain at this time. Resident was helped back in bed. Neuro checks was initiated. Resident continues attempting to get out from the bed. Bed is still in low position. NP was notified, order received for X-ray of the skull, claim No 771. RP was called, but no response, will follow up in the AM. Vital sign B/P 127/66, pulse 70, Resp 18, Temp 97.8. Note was written by RN #10. Record review of CR #98's incident report dated 2/5/19 at 5:51AM revealed an incident description stating, Resident was noted on the floor on his left side. Resident attempted to get up from the bed without assistance. Resident had been noted in bed less than 15 minutes prior to fall resting. Resident was immediately assessed per nurse, hematoma was noted on left forehead. Vital signs were taken with no abnormalities' notes; able to move extremities without difficulty; resident was assisted back in bed per staff and neuro check were initiated - within normal limits at this time. Injuries observed at the time of the incident were a hematoma/bump on the left side of head. Report was completed by RN #10. Record review of CR #98's nurses notes dated 2/5/19 at 6:09AM revealed, Resident was found on floor. Resident was assessed, bump was noted on left forehead. Vital signs were taken, resident was helped back in bed and neuro checks was initiated. Note was written by RN #10. Interview on 2/14/19 at 11:40AM, RN #10 said she was the nurse who found CR #98 on floor on 2/5/19 around 4:00AM. She said the resident had a bruise on the right side of his head from a previous fall. He had a new bump to the left side of his that was swollen. The resident did not complain of pain, she was concerned about the bump to his head, so the NP ordered an X-ray to the skull. She said the resident's fall interventions were to have his bed in low position and close observation. She said the resident had lots of falls and stated, you can see him in bed and as soon as you turn around, he'll fall. Record review of CR #98's nurses notes dated 2/5/19 at 2:51PM revealed, neuros continue; resident noted to have purplish discoloration to both sides of forehead; denies pain or discomfort; X-ray obtained to skull during shift; results pending. Note was written by LVN #6. Interview on 2/14/19 at 10:23AM, LVN #6 said CR #98 fell on the night shift the morning of 2/5/19, she said she worked with the resident the morning shift after the fall and noted discoloration on both sides of his forehead and left eye. The bruising to the right side was from a previous fall. Record review of CR #98's nurses notes dated 2/5/19 at 9:01PM revealed his X-ray results were received. There was no radiographic evidence of acute disease in the skill. The NP was notified, no new order was received. Record review of CR #98's radiology report dated 2/5/19 revealed his skull was examined and the conclusion read in part . There is no radiographic evidence of acute disease in the skull. If there is a high clinical index of suspicion, then CT is recommended because it is a more accurate exam Interview on 2/14/19 at 2:00PM, the DON said she saw CR #98 on 2/8/19 and did not observe any swelling or discoloration to the left side of his head. She said the resident had some old discoloration on his right side from the fall he sustained on 1/21/19 but did not observe anything else on the resident. She said she was not aware of any swelling or bruising to the left side of the resident's forehead or eye. When asked to clarify the nurses notes from 2/5/19 through 2/8/19, she said the nurses were referring to his injuries from 1/21/19 when they mentioned discoloration to the right side. She then said the resident did get a small hematoma from his fall on 2/5/19 but it had resolved, she further said maybe the nurse's got their sides mixed up when documenting injuries to the left side of CR #98 on 2/8/19. Record review of CR #98's Quarterly MDS dated [DATE] revealed CR#98 was severely impaired for cognitive skills and had short- and long-term memory problems. The MDS further revealed CR #98 had fluctuating episodes of disorganized thinking. Transfer - required extensive assistance with two people physical assist. Walk in room - the activity did not occur. Locomotion on unit - required extensive assistance with two people physical assist. Locomotion off unit - required extensive assistance with two people physical assist. Further review of the Quarterly MDS revealed CR #98 had 2 or more falls after his admission to the facility that did not result to injuries and had 2 or more falls that resulted in injury (except major). Record review of CR #98's nurses notes dated 2/9/19 at 4:49AM revealed, Resident noted to be unresponsive at 4:00AM. O2 sat 98% on oxygen (nasal cannula), BP 117/72, HR 98, blood sugar 120mg/dl. RR - none. Code blue called. 911 called. EMS arrived at the facility in 10 minutes. Effort to make him responsive was made but he remained unresponsive. EMS took him to the hospital, family and DON notified. Note was written by RN #12. Interview on 2/16/19 at 10:29AM, RN #12 said he worked the night shift on 2/8/19 and cared for CR #98. He said he had not worked with the resident a lot, he was not very familiar with him, but he was aware he had history of falls. He said he checked on CR #98 every two hours the night of 2/8/19 and found him to be sleeping on and off. He said at 4:00AM, he went in to check on CR #98 and he looked different like he had a change of condition. He said he tried to wake the resident and get him to respond but he did not wake or respond. He checked the resident's vitals and said they were okay, but the resident was still unresponsive. He called for help from another nurse and then called 911. EMS came and tried to get CR #98 to respond as well and were unsuccessful, so they took him to the ER. RN #12 said the resident remained in bed throughout the night and did not have a fall or any other incident throughout the night. RN #12 said the resident did have some bruising and swelling above his eye but could not recall which side it was on. He said the bruising did not appear to be new or very old, he suggested it was about two days old but once again said he was not certain. RN #12 said he had observed the resident with the bruising and swelling at the beginning of his shift and the resident had no changes in his appearance when EMS took the resident out the building. Record review of CR #98's nurses notes dated 2/9/19 at 8:32AM revealed, Received call from MD from hospital; resident currently admitted to the hospital ICU; intubated. Updated RP on resident's status. Record review of CR #98's EMS patient care record dated 2/9/19 at 4:40AM read in part [AGE] year-old male lying in bed with Agonal Respirations at 2 beats per minute (BPM). Staff said the patient was found like this 20-minute prior. Patient has a carotid pulse at 100. EKG-Sinus Tach. Pupils - Non - Reactive. Patient has bruising to left side of his face and left eye. Patient has multiple scratches and bruises to arms and legs. Patient has a feeding tube in place. Patient was ventilated with a BVM at 18 BPM at 25 liters per minute (LPM). Oropharyngeal airway (OPA) placed. Further review revealed in part, Patient was intubated with 8.0 tube place at 27, direct visualization of cords and condensation in tube. ETCO2 - 60. Positive breath sounds in all quads. Patient was ventilated at rate of 12 BPM Record review of CR #98's Emergency Department Final Report dated 2/9/19/ at 5:11AM revealed he arrived at the ER via ambulance and he had been found unresponsive at nursing facility laying on his bed and was intubated in route to the ER. Physical examination revealed old ecchymosis on forehead and scalp. There was a CT to the Brain without contrast done on 2/9/19 at 6:34AM that revealed, 1. Poor grey-white and deep white matter differentiation is present may reflect hypoxic [MEDICAL CONDITIONS]. Please correlate clinically and further workup with MRI brain can be performed for further evaluation if indicated. 2. Prominent left frontal and temporal swelling and hematoma. Interval improvement on the right frontal swelling. Stable postoperative frontal craniotomy with opacification of the frontal sinuses and subjacent bifrontal focal encephalomalacia, left greater than right. The plan was for the resident to be admitted to ICU. Record review of CR #98's Hospital History and Physical final report dated 2/9/19 at 8:20AM revealed the resident had a general appearance of large hematoma on forehead and temporal region. Resident had a CT Scan at 6:34AM with results that are referenced above. The assessment/plan revealed the CT of brain showed possible [MEDICAL CONDITIONS] to be evaluated with MRI once resident was off pressors. Record review of CR #98's Magnetic Resonance Imaging (MRI) without contrast dated 2/9/19 at 8:45am revealed an Impression of, 1. No definite acute territorial infarct or definite hypoxic [MEDICAL CONDITION] detected. 2. Prominent left frontal and temporal swelling and hematoma. Interval improvement of the right frontal swelling. Nonspecific increased signal intensity is present within the posterior left temporal occipital subarachnoid spaces likely compatible with subarachnoid hemorrhage and suspected trace bilateral occipital subdural hemorrhages are present. MRI was done while in the hospital ICU. Record review of CR #98's Final Report Consult Note dated 2/9/19 at 5:36PM revealed in part, EMS was contacted, and he was intubated for [MEDICAL CONDITION] and airway protection. On arrival to the Emergency Department (ED), he received IV fluids and started on empiric antibiotics. He underwent a CT of his head which again revealed stable left temporal frontal scalp hematoma and intracranial changes. He was then transferred to the ICU for further management. There he underwent MRI of the brain which revealed left temporal occipital space subarachnoid hemorrhage and trace bilateral occipital subdural hematomas. Called and discussed the case with neurology they recommended transfer to a Neuro ICU for closer monitoring. I then contacted transfer center with partnering hospital and spoke with neurosurgery on call and they agreed to transfer. During patients stay in the ICU he was weaned completely off of vasoactive medication and a sedation was held. He was awakening at times and moving all extremities. He was not following any commands. Physical exam completed revealed an intubated male with large left sided face hematoma and bruising and normocephalic large left frontal hematoma and surrounding ecchymosis during examination of the head. The final reports plan for neurology revealed, We will continue with sedation with [MEDICATION NAME] for Richmond Agitation and Sedation Scale (RASS) of 0. We will plan for transfer to partnering hospital for further evaluation by neurology. If unable to transfer today, we will begin further imaging studies with Computed tomography [MEDICATION NAME] (CTA). Record review of CR #98's radiology report for CT Head without contrast dated 2/9/19 at 10:07PM revealed in part, Impression: 1. Overall no interval significant adverse changes from prior CT as well as MRI of the brain. 2. Previously identified minimal subarachnoid hemorrhage within left posterior temporal and occipital convexity and minimal subdural hemorrhage along the bilateral occipital convexity, only seen on prior MRI, not confidently identified on the current CT scan. The CT was done at the partnering hospital neuroscience ICU he was transferred to on 2/9/19 at 5:25PM. Record review of CR #98's Neurocore Initial history and physical report dated 2/10/19 at 12:15AM revealed he was being seen to evaluate/treat his critical care nature of the (neuro-relevant) injury/condition. The residents admitting [DIAGNOSES REDACTED]. The chief complaint listed was, questionable occipital subarachnoid hemorrhage (SAH), subdural hematoma (SDH). The History of Present Illness revealed in part, CTH revealed no acute abnormality other than stable previous injuries. MRI brain then revealed possible left temporal subarachnoid hemorrhage (SH) and suspected trace bilateral occipital SDH. Unknown if patient had a recent fall from nursing home. Patient was then transferred to current hospital for higher level of care. Residents past medical Neuro [DIAGNOSES REDACTED]. The radiology comments revealed, Previously identified minimal subarachnoid hemorrhage within left posterior temporal and occipital convexity, only seen on prior MRI, not confidently identified on the current CT scan. Neuro [DIAGNOSES REDACTED]. The plan for the resident's [DIAGNOSES REDACTED]. Record review of CR #98's hospital medical record dated on 2/12/19 at 5:19PM revealed a physical examination of the resident where he was found to have large hematoma over left temple area. The resident hospital face sheet also revealed he chief complaint was SAH. Observation on 2/15/19 at 8:25AM revealed CR #98 was on the neurological floor at the hospital, he was laying in bed and appeared to be at sleep at first glance. The resident awakened and was able to make eye contact, he attempted to speak but was unable to form words. The resident had a large lime sized hematoma over his left eye near his temple area. Resident's left eye had a dark purplish discoloration. Interview on 2/15/19 at 11:15AM, the hospital Director of Neuro ICU and Clinical Manager of Neuroscience said CR #98 had an MRI that showed SAH. A neurosurgeon had diagnosed the resident with traumatic SAH, she explained this meant the hemorrhage was caused by a traumatic event such as a fall. The Director said CR #98 was being monitored and there was no acute surgical intervention needed. Interview on 2/15/19 at 11:30AM, the hospital Quality Manager said CR #98 was triaged at the previous hospital ER to determine what may have caused the resident to become unresponsive. She said the previous hospital ER department conducted several tests and were able to find neurological concerns from the resident's physical evaluation, CT scan and MRI. She said the resident was then transferred to their neuroscience ICU for specialized care and further evaluation. Interview on 2/15/19 at 4:33PM, the Administrator who is the facility's abuse and neglect prohibition coordinator said CR#98's falls did not result in major injuries. The Administrator said the falls with injuries to the resident head were not considered major injuries because he was examined for major injuries with no findings and he was sent out to ER for evaluation on two occasions and was not diagnosed with [REDACTED]. The administrator said falls and incidents were reviewed in their morning meetings to determine if they should be reported to HHSC. Record review of facility Abuse, Neglect, and Exploitation policy (January 2019) revealed, possible indicators of abuse include, but are not limited to: An injury that is suspicious because the source of injury is not observed, or the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. Further review of the policy revealed in part, If actual violation or alleged violation occurs the resident will immediately be assessed and removed from any potential harm (as applicable). The Administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown source, misappropriation of resident property, or involuntary seclusion and report results of the investigation to the enforcement agency in accordance with state law including that state survey and certification agency within five working days of the incident or according to state law. Record review of facility Abuse, Neglect, and Exploitation policy (January 2019) read in part Serious bodily injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; required medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse. Further review of the policy revealed in part .Alleged violations/v (TRUNCATED)

Based on observation, record review, and interview, the facility failed to ensure the resident was free from neglect for one of seven residents, (Resident #1), reviewed for neglect. The facility's van driver (Staff A) failed to report when Resident #1 tipped over in her wheelchair while returning to the facility in the van and sustained a right [MEDICAL CONDITION]. This failure affected one resident and placed seven other residents at risk of experiencing serious pain and injury. Findings include: Incident # 0 Review of Resident #1's clinical records revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Further review of this MDS revealed Resident #1 had short term memory problems, required extensive assistance with transfers, dressing and personal hygiene and was totally dependent on staff for locomotion off the unit and bathing. Resident #1 was dependent on [MEDICAL TREATMENT]. Record review of the facility's Provider Investigation Report, dated, 9/19/17 revealed that on 9/14/17, Resident #1 complained of right leg pain and pain to the right side of her head. She was assessed and noted to have difficulty moving her right leg. Resident #1 reported that her wheelchair had tipped over in the van on the way back from [MEDICAL TREATMENT] on 9/13/17 at 4 p.m. She said the van driver (Staff A) helped her up and back into her chair. The resident was sent to the hospital on [DATE] and was diagnosed with [REDACTED]. Staff at the [MEDICAL TREATMENT] center were interviewed and stated Resident #1 did not complain of pain or exhibit any signs of pain during treatment on 9/13/17. Resident #1 was able to transfer to her wheelchair after [MEDICAL TREATMENT] without pain. Resident #1 was interviewed several times and her account of the incident was consistent. Staff A was immediately suspended and then terminated on 9/18/17. Record review of Resident #1's progress notes, dated 9/14/17 revealed that on 9/14/17, at 12:37 p.m., Resident #1 was in bed and complained of back pain. She was given a head to toe assessment and noted to have a quarter sized raised knot to her right temporal area, a bruise to the right lateral knee, and an inverted right leg. Resident #1 reported a pain level of 10 on a scale of 1-10 with 10 being the highest level. She was given two Tylenol 325 mg tabs for pain. When asked to move her right leg, Resident #1 said she could not move it. When assisted in moving, the resident began to yell. The NP was notified and ordered Resident #1 to be sent to a local hospital. This note was written by the ADON. Record review of Resident #1's care plan, with an onset date of 11/25/15 revealed the resident had the potential for complications due to [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. The goals included: Monitor vital signs as ordered, [MEDICAL TREATMENT] frequency: Monday, Wednesday and Friday. In an interview with the DON on 9/26/17, at 10:00 a.m., she stated on 9/14/17, between 10:00 and 11 a.m., the ADON told her that Resident #1 said she had fallen in the van the day before and Staff A picked her up. The DON said when she assessed the resident, she knew immediately Resident #1 had a broken hip. Resident #1's doctor was in the building and gave orders to send Resident #1 out to the hospital. The DON said she started an investigation immediately. Staff A said it did not happen. Resident #1 had been there since 2008 and never complained about anything. She went to [MEDICAL TREATMENT] three times weekly on Mondays, Wednesdays, and Fridays. Resident #1 was always right on about what she told the staff. She had a low BIMS score of 6, but she could still recall details of the incident. She told the same story five different times. Resident #1 was showered on the evening of 9/12/17. The staff stated she was able to assist in transferring and standing. When Resident #1 returned from [MEDICAL TREATMENT], Staff A said she needed something for pain, but they thought nothing of it because it was usual for the resident to ask for something for pain after [MEDICAL TREATMENT]. Resident #1 did not report the incident until the next day when they noticed the mass on her head, bruised knee and inverted leg and asked if anything happened to cause these injuries. During the investigation the DON discovered that CNA #3 informed Med Aide #2 that Resident #1 was in pain. Med Aide #2, who had been employed with the facility for thirty years and knew Resident #1 well, thought it was unusual for Resident #1 to be in pain on the morning of 9/14/17. Med Aide #2 asked the resident what happened and Resident #1 told her that she had tipped over in the wheelchair yesterday while being transported to [MEDICAL TREATMENT] in the van. Resident #1 said Staff A had not attached the strap that usually went around her shoulder while she was being transported in the van. Resident #1 said the wheelchair tipped over and Staff A helped her back into it. In an interview with Med Aide #2 on 9/26/17, at 1:30 p.m., she stated she was passing medications when CNA #3 said Resident #1 was in pain. Resident #1 never complained of pain. When she went in to see her, Resident #1 was in a lot of pain and said she had tipped over in the van the day before. She then informed the ADON about what Resident #1 said. In an interview on 9/26/17, at 2:00 p.m., CNA #3 said about two weeks ago, she came on shift and checked on Resident #1, who was asleep in bed. She said she went and got a breakfast tray and took it back to Resident #1's room and asked her to sit up. Resident #1 said she could not sit up because she was in pain since the previous night. She said her back and legs were in pain. CNA #3 went to tell Med Aide #2 and the ADON. Med Aide #2 said she did not have anything for pain so the nurse told her to give Resident #1 Tylenol. Med Aide #2 told CNA #3 it was unusual for Resident #1 to be in pain, so she went in and asked what happened. In an attempted interview with Resident #1 on 9/26/17, at 2:45 p.m., she answered, Uhm Hm to every question, even when it was inappropriate. She was in bed on an air mattress with side cushions and a large yellow foam strapped between her legs. She was unable to participate in an interview. Interview with a random nurse at that time revealed that Resident #1 could make her needs known. The nurse said Resident #1 told them she was in pain and recalled the details of the incident in the van on 9/13/17. Observation on 9/26/17 at 3:00 p.m. revealed the van was equipped with shoulder harnesses to secure wheel chairs in the van during transportation. Further observation revealed the shoulder harnesses were working properly. Attempts were made to interview Staff A by phone on 9/26/17, at 3:30 p.m. and on 10/2/17, at 11:54 a.m. The messages were not returned. Record review of Staff A's employee file revealed she received training and a copy of the Vehicle Safety Program Guidelines for Automobiles, Vans and Passenger Vehicles. Further review revealed Staff A received training on abuse and neglect. Further review revealed a progressive discipline form indicating Staff A was terminated on 9/18/17 based on the findings of an investigation conducted between 9/14/17 thru 9/18/17. Record review of the Vehicle Safety Program Guidelines for Automobiles, Vans and Passenger Vehicles dated 6/19/13 revealed in part .Proper use of Tie Downs - Proper use of tie downs will be visible and shown to drivers . Visual Pre-Trip Inspection - Drivers are required to perform a visual inspection of a company vehicle before and after each trip. The visual inspection should include seat belt condition . If any problems are found these must be reported to the center Administrator and documented in writing. Further, a pre-trip inspection checklist is to be used for the vehicle safety inspection and findings are to be documented . Record review of the vehicle Pre-Trip Inspection form for the week of 9/10/17 through 9/16/17 revealed the area which read Check wheelchair securement and occupant restraint belts to ensure functioning properly was initialed as ok on 9/13/17. Record review of the facility's Abuse Policy dated February 2017 revealed that it read in part . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations are reported immediately to the Administrator/Director of Nursing of the center . According to the facility's CMS 672 dated 9/26/17, 7 residents were receiving [MEDICAL TREATMENT].

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of seven residents, (Resident #1), reviewed for accidents and supervision. The facility's van driver (Staff A) failed to fasten the shoulder seat belt around Resident #1 in the van, which caused her to tip over in her wheelchair while returning to the facility in the van. Resident #1 sustained a right hip fracture. This failure affected one resident and placed seven other residents at risk of experiencing serious pain and injury. Findings include: Incident # 0 Review of Resident #1's clinical records revealed an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Further review of this MDS revealed Resident #1 had short term memory problems, required extensive assistance with transfers, dressing and personal hygiene and was totally dependent on staff for locomotion off the unit and bathing. Resident #1 was dependent on renal dialysis. Record review of the facility's Provider Investigation Report, dated, 9/19/17 revealed that on 9/14/17, Resident #1 complained of right leg pain and pain to the right side of her head. She was assessed and noted to have difficulty moving her right leg. Resident #1 reported that her wheelchair had tipped over in the van on the way back from dialysis on 9/13/17 at 4 p.m. She said the van driver (Staff A) helped her up and back into her chair. The resident was sent to the hospital on [DATE] and was diagnosed with [REDACTED]. Staff at the dialysis center were interviewed and stated Resident #1 did not complain of pain or exhibit any signs of pain during treatment on 9/13/17. Resident #1 was able to transfer to her wheelchair after dialysis without pain. Resident #1 was interviewed several times and her account of the incident was consistent. Staff A was immediately suspended and then terminated on 9/18/17. Record review of Resident #1's progress notes, dated 9/14/17 revealed that on 9/14/17, at 12:37 p.m., Resident #1 was in bed and complained of back pain. She was given a head to toe assessment and noted to have a quarter sized raised knot to her right temporal area, a bruise to the right lateral knee, and an inverted right leg. Resident #1 reported a pain level of 10 on a scale of 1-10 with 10 being the highest level. She was given two Tylenol 325 mg tabs for pain. When asked to move her right leg, Resident #1 said she could not move it. When assisted in moving, the resident began to yell. The NP was notified and ordered Resident #1 to be sent to a local hospital. This note was written by the ADON. Record review of Resident #1's care plan, with an onset date of 11/25/15 revealed the resident had the potential for complications due to hemodialysis for end stage renal disease. The goals included: Monitor vital signs as ordered, Dialysis frequency: Monday, Wednesday and Friday. In an interview with the DON on 9/26/17, at 10:00 a.m., she stated on 9/14/17, between 10:00 and 11 a.m., the ADON told her that Resident #1 said she had fallen in the van the day before and Staff A picked her up. The DON said when she assessed the resident, she knew immediately Resident #1 had a broken hip. Resident #1's doctor was in the building and gave orders to send Resident #1 out to the hospital. The DON said she started an investigation immediately. Staff A said it did not happen. Resident #1 had been there since 2008 and never complained about anything. She went to dialysis three times weekly on Mondays, Wednesdays, and Fridays. Resident #1 was always right on about what she told the staff. She had a low BIMS score of 6, but she could still recall details of the incident. She told the same story five different times. Resident #1 was showered on the evening of 9/12/17. The staff stated she was able to assist in transferring and standing. When Resident #1 returned from dialysis, Staff A said she needed something for pain, but they thought nothing of it because it was usual for the resident to ask for something for pain after dialysis. Resident #1 did not report the incident until the next day when they noticed the mass on her head, bruised knee and inverted leg and asked if anything happened to cause these injuries. During the investigation the DON discovered that CNA #3 informed Med Aide #2 that Resident #1 was in pain. Med Aide #2, who had been employed with the facility for thirty years and knew Resident #1 well, thought it was unusual for Resident #1 to be in pain on the morning of 9/14/17. Med Aide #2 asked the resident what happened and Resident #1 told her that she had tipped over in the wheelchair yesterday while being transported to dialysis in the van. Resident #1 said Staff A had not attached the strap that usually went around her shoulder while she was being transported in the van. Resident #1 said the wheelchair tipped over and Staff A helped her back into it. In an interview with Med Aide #2 on 9/26/17, at 1:30 p.m., she stated she was passing medications when CNA #3 said Resident #1 was in pain. Resident #1 never complained of pain. When she went in to see her, Resident #1 was in a lot of pain and said she had tipped over in the van the day before. She then informed the ADON about what Resident #1 said. In an interview on 9/26/17, at 2:00 p.m., CNA #3 said about two weeks ago, she came on shift and checked on Resident #1, who was asleep in bed. She said she went and got a breakfast tray and took it back to Resident #1's room and asked her to sit up. Resident #1 said she could not sit up because she was in pain since the previous night. She said her back and legs were in pain. CNA #3 went to tell Med Aide #2 and the ADON. Med Aide #2 said she did not have anything for pain so the nurse told her to give Resident #1 Tylenol. Med Aide #2 told CNA #3 it was unusual for Resident #1 to be in pain, so she went in and asked what happened. In an attempted interview with Resident #1 on 9/26/17, at 2:45 p.m., she answered, Uhm Hm to every question, even when it was inappropriate. She was in bed on an air mattress with side cushions and a large yellow foam strapped between her legs. She was unable to participate in an interview. Interview with a random nurse at that time revealed that Resident #1 could make her needs known. The nurse said Resident #1 told them she was in pain and recalled the details of the incident in the van on 9/13/17. Observation on 9/26/17 at 3:00 p.m. revealed the van was equipped with shoulder harnesses to secure wheel chairs in the van during transportation. Further observation revealed the shoulder harnesses were working properly. Attempts were made to interview Staff A by phone on 9/26/17, at 3:30 p.m. and on 10/2/17, at 11:54 a.m. The messages were not returned. Record review of Staff A's employee file revealed she received training and a copy of the Vehicle Safety Program Guidelines for Automobiles, Vans and Passenger Vehicles. Further review revealed Staff A received training on abuse and neglect. Further review revealed a progressive discipline form indicating Staff A was terminated on 9/18/17 based on the findings of an investigation conducted between 9/14/17 thru 9/18/17. Record review of the Vehicle Safety Program Guidelines for Automobiles, Vans and Passenger Vehicles dated 6/19/13 revealed in part .Proper use of Tie Downs - Proper use of tie downs will be visible and shown to drivers . Visual Pre-Trip Inspection - Drivers are required to perform a visual inspection of a company vehicle before and after each trip. The visual inspection should include seat belt condition . If any problems are found these must be reported to the center Administrator and documented in writing. Further, a pre-trip inspection checklist is to be used for the vehicle safety inspection and findings are to be documented . Record review of the vehicle Pre-Trip Inspection form for the week of 9/10/17 through 9/16/17 revealed the area which read Check wheelchair securement and occupant restraint belts to ensure functioning properly was initialed as ok on 9/13/17. Record review of the facility's Abuse Policy dated February 2017 revealed that it read in part . Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations are reported immediately to the Administrator/Director of Nursing of the center . According to the facility's CMS 672 dated 9/26/17, 7 residents were receiving dialysis.

Based on observation, record review and interview, the facility failed to maintain acceptable parameters of nutritional status for nine of 18 residents (Residents #5, #11, #15, #33, # 60, #96, #93, #102 and #105) reviewed for weight loss. The facility identified the following residents with weight loss without prompt and effective communication with the Dietician: Resident #11 had severe weight loss of 8.5% in 3 months. Resident #96 had a severe weight loss of 19.7% in 3 months. Resident #5 had severe weight loss of 9% in 4 months. Resident #15 had severe weight loss of 8% in 3 months. Resident #33 had a weight loss of 6.7% in 3 months. Resident #60 had a weight loss of 7% in 2 1/2 months. Resident #93 had a severe weight loss of 14% in 2 months. Resident #102 had a significant weight loss of 7.5% in 3 months. Resident #105 had a severe weight loss of 8.7% in 3 months. The facility did not have a system for documenting accurate meal intake. This failure affected nine residents who had undesired significant or severe weight loss and placed 35 residents at increased risk for weight loss and poor quality of life. Findings included: Resident #11 Record review of Resident #11's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her weight upon admission was 159.6 lbs, height 64. Her [DIAGNOSES REDACTED].>Record review of the Resident #11's annual MDS assessment dated [DATE] revealed she had impaired cognition and required extensive assistance with dressing, eating, and personal hygiene. Further review revealed her height was 64 and weight was 158 lbs. This weight was 12.1 lbs. greater than what was recorded on the weight data log one day before of 145.9 lbs on 03/09/16. Record review of Resident #11's care plan dated 02/10/16 read in part .Resident will have daily needs met .Meal intake - Provide diet as ordered and record intake .(Resident #11) required staff assistance for all ADL's .Give (Resident #11) verbal cues to help prompt .(Resident #11) may need assistance with eating at times . Record review of Resident #11's weight data revealed on 01/05/16 she weighed 163.2 lbs. and on 04/03/16 resident weighed 149 lbs., a 14.2 lb. or 8.5% severe weight loss in 3 months. Record review of Resident #11's RD recommendations dated 10/01/15 read in part .64, 167.6 lbs. No significant weight changes x 6 months. BMI 28.7 overweight. Resident continues on regular, LCS diet . Record review of Resident #11's RD recommendations dated 03/17/16 read in part .64, 145.9 lbs. 14.1 lb (8.8%) x 1 month, 16.5# (10.2%) x 3 months, 19.7# (11.9%) x 6 months. BMI 25. Resident remains on mechanical soft, NLT diet. Intakes as of late have been poor due to illnesses and abt use. Noted that resident c/o stomach cramping .Keep diet liberal for now until intakes improve. Honor food preferences . Record review of Resident #11's RD recommendations dated 04/14/16 read in part .64, 149 lbs. Weight loss 18.6 lbs. (19.2%) x 6 months. Weight trending down. Large weight losses s/p illness with some slight continued losses. Recent SLP eval due to choking on food. Continues on mechanical soft, NTL diet. She requires assistance with meals and has fair PO intakes reported per staff .Will continue to monitor intakes and weights and follow-up . Record review of Resident #11's meal intake for the April 2016 revealed documentation that was made prior to the time for the meal to be served; had different percentages of the amount eaten for the same meal; and had missing documentation as follows: 04/04/16 6:28 PM percentage of Breakfast eaten 75% 04/04/16 6:28 PM percentage of Breakfast eaten 50% alternate offered 04/04/16 6:28 PM percentage of Lunch eaten 75% 04/04/16 6:28 PM percentage of Lunch eaten 25% alternate offered 04/04/16 6:29 PM percentage of Lunch eaten 50% alternate offered 04/04/16 6:35 PM percentage of Lunch eaten 0% nurse notified 04/04/16 6:28 PM percentage of Dinner eaten 50% alternate offered 04/04/16 6:34 PM percentage of Dinner eaten 0% nurse notified 04/09/16 thru 04/10/16 no meal intake documentation recorded 04/11/16 6:38 PM percentage of Lunch eaten 50% alternate offered 04/11/16 6:39 PM percentage of Lunch eaten 75% 04/13/16 no meal intake documentation recorded 04/14/16 1:32 PM percentage of Breakfast eaten 75% 04/14/16 1:31 PM percentage of Breakfast eaten 50% alternate offered 04/14/16 1:31 PM percentage of Lunch eaten 50% alternate offered 04/14/16 1:31 PM percentage of Lunch eaten 75% 04/14/16 1:31 PM percentage of Dinner eaten 75% 04/14/16 1:31 PM percentage of Dinner eaten 50% alternate offered 04/15/16 1:43 PM percentage of Dinner eaten 75% 04/16/16 thru 04/20/16 no meal intake documentation recorded 04/21/16 3:11 PM percentage of Breakfast eaten 75% 04/21/16 3:12 PM percentage of Breakfast eaten 50% alternate offered 04/21/16 3:11 PM percentage of Lunch eaten 50% alternate offered 04/21/16 3:12 PM percentage of Lunch eaten 25% alternate offered 04/21/16 3:12 PM percentage of Lunch eaten 75% 04/21/16 3:11 PM percentage of Dinner eaten 50% alternate offered 04/21/16 6:55 PM percentage of Dinner eaten 75% 04/23/16 no documentation of percentage of Lunch or Dinner eaten 04/24/16 no meal intake documentation recorded 04/25/16 2:06 PM percentage of Breakfast eaten 100% 04/25/16 2:06 PM percentage of Breakfast eaten 75% 04/25/16 2:07 PM percentage of Breakfast eaten 50% alternate offered 04/25/16 2:06 PM percentage of Lunch eaten 100% 04/25/16 2:06 PM percentage of Lunch eaten 75% 04/25/16 2:06 PM percentage of Lunch eaten 50% alternate offered 04/25/16 2:06 PM percentage of Dinner eaten 25% alternate offered 04/25/16 2:06 PM percentage of Dinner eaten 75% 04/26/16 1:15 PM percentage of Dinner eaten 50% alternate offered Record review of Resident #11's dietary slip revealed she was currently being served a mechanical soft diet with nectar thick liquids. Observation and interview on 04/28/16 at 12 noon in the dining room revealed Resident #11 was on mechanical soft diet. Resident #11 stated she was a diabetic, which was not indicated on her diet card. She also stated she was not allowed to have a lot of starch in her diet. Resident consumed 25% of the lunch meal. Observation of the lunch menu on 04/28/16 at 12 noon revealed the following was on the menu: Chili Dog on a Bun, French Fries, Coleslaw, and Chocolate Pudding. Alternate choice on the menu: Smothered Chicken (baked boneless chicken with a white gravy). Interview on 04/28/16 at 12 noon the RD stated the menus were provided by corporate and they were expected to follow them. She agreed the menu was heavy on starch and needed more vegetables. Interview on 04/28/16 at 12 noon the Dietary Manager stated the menus were provided by corporate and they were expected to follow them. She agreed the menus were heavy on starch and should have more vegetables. Resident #96 Record review of Resident #96's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her weight upon admission was 92.5 lbs. Her [DIAGNOSES REDACTED]. Record review of Resident #96's quarterly MDS dated [DATE] revealed she weighed 80 lbs., her cognition was severely impaired, she required extensive assistance with transfers, ambulation, dressing, eating and personal hygiene. Further review of this MDS revealed the resident's weight was 80 lbs., and she had weight loss. Record review of Resident #96's care plan dated 03/03/16 read in part .is unable to take in adequate nutrition. I have always been a picky eater, and tend not eat at all but I do drink my supplemental/nutritional drink most times .RD to evaluate current nutritional status . offer food alternatives when appropriate for any meal served . provide with verbal encouragement/cueing . weigh monthly .provide with assistance with meals as needed . I have had a weight loss due to poor intake and I need lots of encouragement to drink supplements .Monitor my intake . Observe for changes in my condition that may warrant increased supervision/assistance with nutritional intake and notify the physician . Record review of Resident #96's weight log revealed she weighed 92.5 lbs. on 01/05/16, she weighed 83.8 lbs on 03/01/16, and on 03/30/16 she weighed 74.2 lbs, a 19.7% severe weight loss in 3 months. Record review of Resident #96's RD notes dated 03/17/16 read in part .64, 80.4 lbs., weight loss 8.6 lbs (9.7 %) x one month. BMI 13.8 underweight. Resident continues on mechanical soft, ground meats. She is fed by staff with intakes 0% to 25 % on average. Supplements include: 2.0 house supplement 120 ml QID .Continue supplementation and keep diet liberal to enhance palatability of diet. Will monitor and follow up .Addendum 1. Add fortified cereal at breakfast . Record review of Resident #96's RD notes dated 04/14/16 read in part .64, 78 lbs, weight loss 14.5 lbs. (15.7%) x 3 months .BMI 13.4 underweight .Resident continues on mechanical soft, ground meats diet. She requires assistance with meals due to difficulty manipulating utensils due to contractures. Intakes 25% per staff .Assist with all meals. Continue weekly weights. Honor food preferences and keep dietary restrictions minimal due to altered diet textures . Record review of Resident #96's dietary slip revealed she received a mechanical soft diet. Observation on 04/28/16 at 12 noon in the dining room revealed Resident #96 consumed 50% of the lunch meal. No one assisted Resident #96 with eating during this lunch meal. Record review of Resident #96's meal intake for the month of April 2016 revealed documentation that was made prior to the time for the meal to be served; had different percentages of the amount eaten for the same meal; and had missing documentation as follows: 04/02/16 11:32 AM percentage of Dinner eaten 50% 04/03/16 and 04/04/16 no documentation of percentage of Dinner eaten 04/05/16 7:29 PM percentage of Dinner eaten 25% alternate offered 04/05/16 7:29 PM percentage of Dinner eaten 50% alternate offered 04/09/16 no meal intake documentation recorded 04/10/16 9:00 AM percentage of Dinner eaten 100% 04/12/16 no documentation of percentage of Dinner eaten 04/13/16 thru 04/16/16 no meal intake documentation recorded 04/17/16 9:31 AM percentage of Dinner eaten 25% alternate offered 04/18/16 thru 04/20/16 no meal intake documentation recorded 04/21/16 11:12 AM percentage of Breakfast eaten 50% alternate offered 04/21/16 11:12 AM percentage of Breakfast eaten 100% 04/21/16 11:12 AM percentage of Dinner eaten 50% alternate offered 04/22/16 no documentation of percentage of Dinner eaten 04/24/16 thru 04/25/16 no meal intake documentation recorded 04/26/16 4:37 PM percentage of Lunch eaten 50% alternate offered 04/26/16 4:37 PM percentage of Lunch eaten 75% 04/26/16 4:38 PM percentage of Dinner eaten 75% 04/26/16 4:38 PM percentage of Dinner eaten 25% alternate offered Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of resident #5's MDS annual assessment dated [DATE] revealed that she was severely impaired for cognition and required extensive assistance with eating, dressing and personal hygiene. Further review of this MDS revealed Resident #5's weight was 105 lbs. Record review of Resident #5's care plan, which was undated, read in part .(Resident #5) will have daily needs met. Meal intake - Provide diet as ordered and record intake . At risk for labile blood sugars related to Type II diabetes mellitus .Monitor nutritional intake and diet as ordered .Refer to a dietician as needed . Further review of this care plan revealed it did not address Resident #5's weight loss. Record review of Resident #5's RD recommendation form dated 04/17/15 read in part .HT: 54, weight 103.8 lbs, BMI: 25.0 (desirable), IBW: 120 lbs . Record review of Resident #5's speech therapy plan of care dated 04/25/15 revealed Resident #5 demonstrated gagging and difficulty with feeding, decline in PO intake, and required assistance with feedings. Record review of Resident #5's RD recommendations revealed there were no notes from 11/19/15 until 04/21/16. Record review of Resident #5's weight data log revealed on 12/21/15 she weighed 108.2 lbs. and on 04/01/16 the resident weighed 98.4 lbs. (a 9% severe weight loss in 4 months). Record review of Resident #5's Registered Dietitian's (RD) recommendation dated 04/21/16, (three weeks after the 9% weight loss was identified) read in part .HT: 54 weight 98.6 lbs. Weight loss 6.6 lbs. (6.3%) x 1 month. Resident remains on pureed diet. Intakes have been somewhat poor as of late. Typical intakes 25%. Sits in assisted feeding room. Noted psychological issues. She has contractures and requires to be fed meals .Continue to feed resident all meals . Observation on 04/28/16 at 10:00 A.M. of a sign posted by the dining room revealed breakfast was served at 8 AM, lunch was served at 12 noon and dinner was served at 5 PM. Record review of Resident #5's dietary slip revealed the resident was currently being served a pureed diet. Observation on 04/28/16 at 12 noon revealed Resident #5 was eating a pureed diet. She was being assisted with her meal; but refused the meal. She was offered ice cream but refused to eat it. Resident #5 ate 0% of the lunch meal. Record review of Resident #5's meal intake for the month of April 2016 revealed documentation that was made prior to the time for the meal to be served; had different percentages of the amount eaten for the same meal; and had missing documentation as follows: 04/04/16 6:55 PM percentage of Breakfast eaten 0% nurse notified 04/04/16 6:55 PM percentage of Breakfast eaten 25% alternate offered 04/04/16 6:55 PM percentage of Breakfast eaten 50% alternate offered 04/04/16 6:55 PM percentage of Lunch eaten 25% alternate offered 04/04/16 6:55 PM percentage of Lunch eaten 50% alternate offered 04/04/16 6:55 PM percentage of Dinner eaten 25% alternate offered 04/04/16 6:55 PM percentage of Dinner eaten 50% alternate offered 04/09/16 no meal intake documentation recorded 04/10/16 no documentation of the percentage of Dinner eaten 04/11/16 7:26 PM percentage of Dinner eaten 25% alternate offered 04/11/16 7:26 PM percentage of Dinner eaten 50% alternate offered 04/12/16 no documentation of the percentage of Dinner eaten 04/13/16 no documentation of the percentage of Dinner eaten 04/14/16 1:44 PM percentage of Dinner eaten 25% alternate offered 04/15/16 1:50 PM percentage of Dinner eaten 25% alternate offered 04/16/16 no documentation of the percentage of Lunch or Dinner eaten 04/17/16 9:27 AM percentage of Dinner eaten 25% alternate offered 04/18/16 thru 04/20/16 no meal intake documentation recorded 04/21/16 7:15 PM percentage of Lunch eaten 50% alternate offered 04/21/16 7:15 PM percentage of Lunch eaten 75% 04/21/16 7:15 PM percentage of Lunch eaten 0% nurse notified 04/21/16 7:15 PM percentage of Dinner eaten 25% alternate offered 04/21/16 7:15 PM percentage of Dinner eaten 75% 04/21/16 7:15 PM percentage of Dinner eaten 50% alternate offered 04/24/16 thru 04/25/16 no meal intake documentation recorded 04/26/16 1:29 PM percentage of Breakfast eaten 25% alternate offered 04/26/16 1:29 PM percentage of Breakfast eaten 75% 04/26/16 1:29 PM percentage of Lunch eaten 50% alternate offered 04/26/16 1:29 PM percentage of Lunch eaten 25% alternate offered 04/26/16 1:29 PM percentage of Dinner eaten 50% alternate offered 04/26/16 1:29 PM percentage of Dinner eaten 25% alternate offered Interview on 04/28/16 at 12:00 PM, CNA #17 said all resident meal intake was to be recorded in the computer system after the meal service had ended. Interview on 04/28/16 at 12:15 PM, the Dietician stated she utilized the meal intake data entered into the computer system to complete her resident assessments. Resident #15 Record review of Resident #15's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her weight upon admission was 147.6 lbs, height 68. Her [DIAGNOSES REDACTED]. Record review of Resident #15's quarterly MDS dated [DATE] revealed that resident #15 weighed 135 lbs. No code was entered in reference to a weight loss or weight gain though the resident had a weight loss of 11 lbs. between 01/02/16 and 04/15/16 a 8% weight loss in 3 months. Record review of Resident #15's care plan, which was undated, read in part .Meal intake - Provide diet as ordered and record intake .requires staff assistance for most of her ADL's .Give verbal cues to help prompt . Further review of this care plan revealed her weight loss was not addressed. Record review of resident #15's weight data revealed on 01/02/16 she weighed 144 lbs.; on 02/17/16 she weighed 133 lbs.; and on 03/31/16 she weighed 132.2 lbs, an 8% severe weight loss in 3 months. Record review of Resident #15's RD notes dated 03/03/16 (15 days after a weight loss of 12.8 lbs. was identified) read in part .weight loss of 12.8 lbs. since admission (11/11/15) .BMI 20.5 Resident continues on Regular diet. She is able to feed herself and has fair PO intakes .She does have confusion and needs to be reminded of meal times and cued and encouraged during meals at times .Will monitor and follow-up . Record review of Resident #15's dietary slip revealed she received a regular diet. Observation on 04/28/16 at 12 noon in the dining room revealed Resident #15 was assisted by the staff with her meal. Record review of Resident #15's meal intake for the month of April 2016 revealed documentation that was made prior to the time for the meal to be served; had different percentages of the amount eaten for the same meal; and had missing documentation as follows: 04/10/16 8:38 AM percentage of Lunch eaten 100% 04/10/16 no documentation of dinner percentage eaten 04/11/16 6:35 PM percentage of breakfast eaten 50% alternate offered 04/11/16 6:35 PM percentage of breakfast eaten 75% 04/11/16 6:35 PM percentage of dinner eaten 50% alternate offered 04/11/16 6:35 PM percentage of dinner eaten 75% 04/12/16 no documentation of dinner percentage eaten 04/13/16 no meal intake documentation recorded 04/14/16 1:29 PM percentage of breakfast eaten 75% 04/14/16 1:29 PM percentage of breakfast eaten 50% alternate offered 04/14/16 1:29 PM percentage of Dinner eaten 50% alternate offered 04/15/16 1:42 PM percentage of Dinner eaten 25% alternate offered 04/16/16 only the breakfast meal intake was recorded 04/17/16 1:32 PM percentage of Dinner eaten 75% 04/18/16 thru 04/20/16 no meal intake documentation recorded 04/21/16 3:06 PM percentage of breakfast eaten 75% 04/21/16 3:07 PM percentage of breakfast eaten 50% alternate offered 04/21/16 3:06 PM percentage of Dinner eaten 50% alternate offered 04/21/16 3:06 PM percentage of Dinner eaten 100% 04/23/16 only the breakfast meal intake was documented 04/24/16 no meal intake documentation was made for this day 04/25/16 2:04 PM percentage of Dinner eaten 75% 04/26/16 1:14 PM percentage of Dinner eaten 50% alternate offered 04/27/16 no documentation of percentage of Dinner eaten Resident #33 Record review of Resident #33's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #33's MDS dated [DATE] revealed she weighed 137 lbs. was severely cognitively impaired and required extensive assistance with transfers, ambulation, dressing, eating and personal hygiene. No code was entered in reference to a weight loss or weight gain though the resident had a weight loss of 9.3 lbs. between 01/03/16 and 04/03/16 a 6.7% weight loss in 3 months. Record review of Resident #33's care plan, which was undated, read in part .has had fluctuating intake of her Puree diet and does not always allow assistance from staff. Staff will encourage (Resident #33) and assist her to dining room for meals. Dietician will review at regular intervals. Weights as ordered and PRN .will have daily needs met. Meal intake - Provide diet as ordered and record intake . Record review of Resident #33 weight log data revealed on 01/03/16 resident weighed 136.8 lbs and on 04/03/16 she weighed 127.5 lbs, a 6.7% weight loss in 3 months. Record review of Resident #33's RD notes dated 08/06/15 read in part .63, 145.2 lbs., BMI 25.7. Resident continues on pureed diet with large meat/egg portions . Record review of Resident #33's RD notes dated 09/23/15 read in part .63, 134 lbs, weight loss of 10.8 lbs (7.4%) x 1 month. Resident continues on pureed diet, large meat/egg portions. She requires some assistance and supervision with meals, but mostly is able to feed herself. She has good PO intakes and often snacks between meals as well .Monitor weights weekly due to variances. Will follow up . Record review of Resident #33's RD notes revealed there were no other notes from 09/23/15 until 03/17/16. Record review of Resident #33's RD notes dated 03/17/16 read in part .63, 126.2 lbs, weight loss of 7.3 lbs. (5.5%) x 1 month, 10.8 lbs (7.9%) x 3 months. BMI 22.4. Resident continues on pureed, large meat/egg portions. Intakes are on average 75%. Resident is confused and needs redirection during meals and reminding of meal times . Record review of Resident #33's dietary slip revealed she was on a pureed diet with large meat/egg portions. Observation on 04/28/16 at 12 noon in the dining room revealed Resident #33 consumed 75% of the lunch meal. Record review of Resident #33's meal intake for the month of April 2016 revealed documentation that was made prior to the time for the meal to be served; had different percentages of the amount eaten for the same meal; and had missing documentation as follows: 04/03/16 10:59 PM percentage of Breakfast eaten 75% 04/03/16 10:59 PM percentage of Breakfast eaten 100% 04/03/16 10:59 PM percentage of Lunch eaten 100% 04/03/16 10:59 PM percentage of Lunch eaten 75% 04/03/16 10:59 PM percentage of Dinner eaten 100% 04/04/16 6:48 PM percentage of Breakfast eaten 75% 04/04/16 6:48 PM percentage of Breakfast eaten 100% 04/04/16 no documentation of percentage of Dinner eaten 04/09/16 and 04/10/16 no meal intake documentation recorded 04/11/16 6:54 PM percentage of Breakfast eaten 75% 04/11/16 6:54 PM percentage of Breakfast eaten 100% 04/11/16 6:54 PM percentage of breakfast eaten 50% alternate offered 04/11/16 6:54 PM percentage of Dinner eaten 75% 04/11/16 6:54 PM percentage of Dinner eaten 100% 04/13/16 no meal intake documentation recorded 04/14/16 1:40 PM percentage of Breakfast eaten 100% 04/14/16 1:40 PM percentage of Breakfast eaten 75% 04/14/16 1:40 PM percentage of Lunch eaten 50% alternate offered 04/14/16 1:40 PM percentage of Lunch eaten 100% 04/14/16 1:40 PM percentage of Dinner eaten 50% alternate offered 04/14/16 1:40 PM percentage of Dinner eaten 50% alternate offered 04/15/16 1:48 PM percentage of Dinner eaten 75% 04/16/16 thru 04/18/16 no meal intake documentation recorded 04/19/16 no documentation of percentage of Breakfast or Lunch intake 04/19/16 10:22 PM percentage of Dinner eaten 100% 04/19/16 10:22 PM percentage of Dinner eaten 75% 04/20/16 no meal intake documentation recorded 04/21/16 7:02 PM percentage of Breakfast eaten 100% 04/21/16 7:02 PM percentage of Breakfast eaten 50% alternate offered 04/21/16 7:02 PM percentage of Breakfast eaten 75% alternate offered 04/21/16 7:02 PM percentage of Dinner eaten 50% alternate offered 04/21/16 7:02 PM percentage of Dinner eaten 75% alternate offered 04/23/16 thru 04/25/16 no meal intake documentation recorded 04/26/16 1:23 PM percentage of Lunch eaten 100% 04/26/16 1:23 PM percentage of Lunch eaten 75% 04/26/16 1:23 PM percentage of Dinner eaten 100% 04/26/16 1:23 PM percentage of Dinner eaten 50% alternate offered 04/26/16 7:01 PM percentage of Dinner eaten 75% 04/27/16 no documentation of percentage of Dinner eaten Resident #60 Record review of Resident #60's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her weight upon admission was 164 lbs., height 66. Her [DIAGNOSES REDACTED]. Record review Resident #60's care plan dated 02/15/16 read in part .Resident will have daily needs met .Meal intake - Provide diet as ordered and record intake . Further review revealed no care plan to address weight loss. Record review of Resident #60's quarterly MDS dated [DATE] revealed her weight was 167 lbs., she had moderate cognitive impairment, and required extensive assistance with transfers, ambulation, dressing, eating, and personal hygiene. No code was entered in reference to a weight loss or weight gain. Record review of Resident #60's weight data log revealed on 01/17/16 she weighed 164 lbs, on 02/03/16 she weighed 163.4 lbs, on 03/01/16 she weighed 153.8 lbs., and on 03/26/16 she weighed 151.8 lbs, a weight loss of 7% in 2 1/2 months. Record review Resident #60's RD notes dated 03/17/16 read in part .66, 153.8%, weight loss of 9.6 lbs (5.9%) x 1 month. BMI 24.8. Resident continues on Regular diet. Due to confusion and disorientation, she is fed per staff with fair to poor PO intakes. Intakes per ADLs reported on average between 25-50% . (Resident #60's weight was taken on 03/01/16 but the intervention by the RD was not done until 03/17/16.) Record review of Resident #60's RD notes dated 04/14/16 read in part .66, 151.8 lbs, weight loss 12.2 lbs (7.4%) x 3 months. Continues to trend down. BMI 24.5. Resident continues on Regular diet. She is confused and requires to be fed per staff with intakes generally 25-50% . Record review of Resident #60's dietary slip revealed she received a regular diet. Observation 04/28/16 at 12 noon in the dining room revealed Resident #60's husband was feeding her a regular diet. Resident #60 consumed 50% of the lunch meal. Record review of Resident #60's meal intake for the month of April 2016 revealed documentation that was made prior to the time for the meal to be served; had different percentages of the amount eaten for the same meal; and had missing documentation as follows: 04/04/16 no documentation of percentage of Breakfast or Lunch eaten 04/04/16 9:43 PM percentage of Dinner eaten 25% alternate offered 04/04/16 9:45 PM percentage of Dinner eaten 75% 04/09/16 no documentation of percentage of Breakfast or Lunch eaten 04/10/16 8:43 AM percentage of Breakfast eaten 100% 04/10/16 8:43 AM percentage of Breakfast eaten 75% 04/10/16 8:43 AM percentage of Lunch eaten 75% 04/10/16 1:49 PM percentage of Lunch eaten 100% 04/10/16 no documentation of percentage of Dinner eaten 04/11/16 7:51 PM percentage of dinner eaten 0% nurse notified 04/11/16 7:51 PM percentage of Dinner eaten 25% alternate offered 04/12/16 no documentation of percentage eaten for this day 04/13/16 no documentation of percentage of Breakfast or Lunch eaten 04/14/16 thru 04/16/16 no meal intake documentation recorded 04/17/16 1:42 PM percentage of Breakfast eaten 50% alternate offered 04/17/16 1:43 PM percentage of Breakfast eaten 100% 04/17/16 1:43 PM percentage of Lunch eaten 100% 04/17/16 1:43 PM percentage of Lunch eaten 50% alternate offered 04/17/16 1:43 PM percentage of Dinner eaten 50% alternate offered 04/17/16 1:43 PM percentage of Dinner eaten 100% 04/18/16 and 04/19/16 no meal intake documentation recorded 04/20/16 and 04/21/16 no documentation of percentage of Breakfast or Lunch eaten 04/22/16 7:41 PM percentage of Breakfast eaten 100% 04/22/16 7:41 PM percentage of Breakfast eaten 75% 04/22/16 7:41 PM percentage of Lunch eaten 75% 04/22/16 7:41 PM percentage of Lunch eaten 100% 04/22/16 7:41 PM percentage of Lunch eaten 50% alternate offered 04/22/16 7:41 PM percentage of Dinner eaten 25% alternate offered 04/22/16 7:41 PM percentage of Dinner eaten 0% nurse notified 04/23/16 no documentation of percentage of Lunch or dinner eaten 04/24/16 and 04/125/16 no meal intake documentation recorded 04/26/16 3:59 PM percentage of Breakfast eaten 75% 04/26/16 3:59 PM percentage of Breakfast eaten 100% Resident #93 Record review of Resident #93's face sheet revealed a [AGE] year old female admitted on [DATE]. Her weight upon admission was 147.8 lbs. Her [DIAGNOSES REDACTED]. Record review of Resident #93's quarterly MDS dated [DATE] revealed she weighed 147 lbs, was moderately cognitively impaired, and required supervision, encouragement or cueing with eating. No code was entered in reference to a weight loss or weight gain. Record review of Resident #93's care plan dated 03/03/16 read in part .Resident will have daily needs met .Meal intake - Provide diet as ordered and record intake .will maintain current weight within 5 lbs and reduce risk for further wt. loss .Registered Dietician to evaluate current nutritional status .offer food alternatives when appropriate for any meal served .weigh monthly . Record review of Resident #93's weight data revealed on 01/13/16 and 02/20/16 she weighed 147.8 lbs, and on 03/26/16 she weighed 127 lbs a 14% severe weight loss in 2 months. Record review of Resident #93's RD notes dated 02/09/16 noted read in part .63, 129 lbs. Noted large weight fluctuation. Will continue to monitor. Hx of fluid retention. She continued on mechanical soft diet

Based on interview, and record review, the facility failed to ensure each resident had the right to formulate an advance directive for code status for one of 11 residents (CR#1) reviewed for Advance Directives. CR #1 was admitted to the facility on [DATE] with conflicting information about whether she was a full code or a DNR, which caused a delay in receiving prompt CPR after she experienced a change in condition. This failure affected one resident and placed 113 residents at risk of not receiving prompt medical intervention in the event of an emergency, which could lead to a resident being resuscitated or allowed to die without intervention, against their wishes. Findings include: Intake # 4 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] at 12:00p.m. She had the following Diagnoses: [REDACTED]. Further review of this face sheet revealed no advanced directive. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's hospital record dated [DATE] revealed no advance directives completed by the patient or responsible party. The Code status read CPR - No. Record review of CR #1's out of hospital do-not resuscitate form revealed it was signed by her physician but the rest of the form was blank and CR #1's information was not filled in. Record review of CR #1's nurses' notes dated [DATE] revealed the following: Resident arrived at 12:15p.m., per EMS with two attendants, Resident transported per stretcher into facility. Residents is a [AGE] year old white female, alert to person and able to make simple needs known, resident on oxygen at 54 liters via nasal cannula. Oxygen saturation ,[DATE]% upon arrival. Resident to be on oxygen at 4 liters. [MEDICAL CONDITION] during the night. Resident with a skin tear to right anterior wrist area with a 3cm by 4 cm pink bruise to anterior arm. Dressing intact to right upper arm from IV removal. Resident with dressing to back of the left arm. Medications were called into IPC, OK to continue discharged medications. Record review of CR #1's nurses' notes dated [DATE] at 11:11p.m. revealed the following vital signs: temperature 97.2, respiration - 21, blood pressure ,[DATE], oxygen saturation of 96% and heart rate - 84. Record review of CR #1's nurses' notes dated [DATE] at 1:51a.m., revealed at 12:30a.m., CNA called nurse to the room stating that he wants to change resident but she seems to be having difficulty breathing, Nurse (LVN #1) immediately went to resident's room. Noticed deep labored breathing, resident had [MEDICAL CONDITION] mask firmly clutched in the right hand which was on the side of her leg. [MEDICAL CONDITION] mask replaced on the resident, oxygen saturation checked, unable to register a number, pulse noted, no response to verbal stimuli from staff, Nurse immediately called evening nurse to see if this is a change in resident. Evening nurse immediately stated call 911 due to a major change. Resident was alert and talking during evening shift. Night nurse noticed when passing by the room at 10:35p.m. that the resident was watching television with [MEDICAL CONDITION] machine on. Record review of CR #1's nurses' notes dated [DATE] revealed the following: At 12:25a.m., revealed 911 called for resident to be transported for respiratory distress, call placed to resident's (family member) four times to inform her that there is a change for medical status of her mom and that she might be transported to hospital but there was no response from her. Left message to voice mail. At 12:42a.m., revealed EMS on site, no pulse noted at present, nurse taking crash cart to room but EMS had initiated CPR. At 1:10A.M., revealed EMS leaving with resident to hospital, call placed to resident (family member) again, message left informing her (CR #1) is being transported to hospital. MD will be notified that resident was out. Record review of CR #1's EMS report dated [DATE] revealed dispatched to emergency transfer, upon arrival facility staff stated the patient had been altered and that triggered the 911 call. During EMS being dispatched and then going enroute and on scene, the patient arrested. Upon EMS arrival, she was found apneic and pulseless. Staff stated that she was a DNR patient so EMS stated there was nothing for EMS to do. EMS was about to return to service when the staff stated that the DNR was not valid. Upon inspection, the DNR paperwork had not been completed. It had a physician's signature but absolutely no patient information had been entered in on the DNR form. EMS attempted to contact the next of kin with no success. Staff was also unsuccessful in contacting next of kin. CPR was initiated, patient was found asystole, CPR was started with the Lucas and patient had intravenous attempted, EJ intravenous was unsuccessful, established successfully on patient's left tibia. Intubation performed successfully, asytole/PEA protocol worked per guidelines. Two EPIS and 40 vaso administered. After 3rd round of drugs, patient regained and retained pulse through rest of treatment and transport. Patient was taken to hospital and care transferred to ER staff. Interview on [DATE] at 3:03p.m., CR #1's family member stated she was the resident's POA. She explained upon discharge from hospital the physician had given her forms for out of hospital do not resuscitate with only the physician signature on the form. She said this was in case the family decided on DNR status. CR #1's family member said DNR was not discussed with anyone during the resident's admission to the facility but she handed the staff all the discharge documents including the blank DNR form. She said the resident was full code and she believed the resident did not receive prompt resuscitation from the facility when found unresponsive. Interview on [DATE] at 2:27p.m., RN #1 said he was called by the charge nurse around 1:00a.m. on [DATE] to assess CR #1, who had a change in condition. He said he had completed the resident's admission and checked her vital signs about 7p.m. so he was familiar with the resident's normal condition. RN #1 said upon entering CR #1's room on [DATE] around 1:00a.m., he noted she had a change in condition from when he admitted her. He said her head was slumped down and she was not responding verbally. RN #1 said he called CR #1's responsible party and left messages twice. He said the resident's DNR form had a physician's signature only and the patient's information was not filled in. RN #1 said EMS asked why they were called since CR #1 had a DNR and RN#1 told them the form was invalid. RN #1 said EMS asked to see the form then proceeded to CR #1's room to initiate CPR. Interview on [DATE] at 2:27p.m., LVN #1 said CR #1 was noted on [DATE] around 12 midnight to have difficulty breathing, oxygen saturation was not readable and the resident's pulse was faint. She said she was unable to read the pulse because it was very faint. LVN #1 said she thought she recorded the resident's vital signs during the change in condition. She further stated she was getting paperwork ready for EMS while the supervisor, RN #1, was on the phone with 911. LVN #1 said while she was in CR #1's room she heard someone say I think she gave her last breath. LVN #1 said 911 was pulling up at that time and people were heading down the hall with the crash cart, but EMS had already initiated CPR as the crash cart was brought into the room. LVN #1 was unsure of the resident's code status. She stated she heard RN #1 discussing it. Interview on [DATE] about 2:30p.m., the DON said CR #1 was a full code. The DON stated CR #1 admitted to the facility on [DATE], had a change in condition a couple of hours following admission and staff called 911. The DON said CR #1 did not initially receive CPR because she had a pulse and was breathing. The DON further explained that at the time staff reported the resident stopped breathing 911 arrived and began CPR. The DON said she had evaluated the incident and believed staff did what was expected of them. The DON further said the resident was a full code which should have been clearly identified on her chart on admission but instead the incomplete out of hospital DNR form and hospital records that read No CPR created conflicting information. According to the DON, the facility had no advance directive policy. Facility census listed 113 residents.

Based on interview, and record review, the facility failed to ensure each resident had the right to formulate an advance directive for code status for one of 11 residents (CR#1) reviewed for Advance Directives. The facility failed to maintain a policy and procedure regarding Advance Directives and provide a copy of that policy and procedure to CR #1 or her responsible party upon admission. This failure affected one resident and placed 113 residents at risk of not receiving prompt medical intervention in the event of an emergency, which could lead to a resident being resuscitated or allowed to die without intervention, against their wishes. Findings include: Intake # 4 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] at 12:00p.m. She had the following Diagnoses: [REDACTED]. Further review of this face sheet revealed no advanced directive. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's hospital record dated [DATE] revealed no advance directives completed by the patient or responsible party. The Code status read CPR - No. Record review of CR #1's out of hospital do-not resuscitate form revealed it was signed by her physician but the rest of the form was blank and CR #1's information was not filled in. Record review of CR #1's nurses' notes dated [DATE] revealed the following: Resident arrived at 12:15p.m., per EMS with two attendants, Resident transported per stretcher into facility. Residents is a [AGE] year old white female, alert to person and able to make simple needs known, resident on oxygen at 54 liters via nasal cannula. Oxygen saturation ,[DATE]% upon arrival. Resident to be on oxygen at 4 liters. [MEDICAL CONDITION] during the night. Resident with a skin tear to right anterior wrist area with a 3cm by 4 cm pink bruise to anterior arm. Dressing intact to right upper arm from IV removal. Resident with dressing to back of the left arm. Medications were called into IPC, OK to continue discharged medications. Record review of CR #1's nurses' notes dated [DATE] at 11:11p.m. revealed the following vital signs: temperature 97.2, respiration - 21, blood pressure ,[DATE], oxygen saturation of 96% and heart rate - 84. Record review of CR #1's nurses' notes dated [DATE] at 1:51a.m., revealed at 12:30a.m., CNA called nurse to the room stating that he wants to change resident but she seems to be having difficulty breathing, Nurse (LVN #1) immediately went to resident's room. Noticed deep labored breathing, resident had [MEDICAL CONDITION] mask firmly clutched in the right hand which was on the side of her leg. [MEDICAL CONDITION] mask replaced on the resident, oxygen saturation checked, unable to register a number, pulse noted, no response to verbal stimuli from staff, Nurse immediately called evening nurse to see if this is a change in resident. Evening nurse immediately stated call 911 due to a major change. Resident was alert and talking during evening shift. Night nurse noticed when passing by the room at 10:35p.m. that the resident was watching television with [MEDICAL CONDITION] machine on. Record review of CR #1's nurses' notes dated [DATE] revealed the following: At 12:25a.m., revealed 911 called for resident to be transported for respiratory distress, call placed to resident's (family member) four times to inform her that there is a change for medical status of her mom and that she might be transported to hospital but there was no response from her. Left message to voice mail. At 12:42a.m., revealed EMS on site, no pulse noted at present, nurse taking crash cart to room but EMS had initiated CPR. At 1:10A.M., revealed EMS leaving with resident to hospital, call placed to resident (family member) again, message left informing her (CR #1) is being transported to hospital. MD will be notified that resident was out. Record review of CR #1's EMS report dated [DATE] revealed dispatched to emergency transfer, upon arrival facility staff stated the patient had been altered and that triggered the 911 call. During EMS being dispatched and then going enroute and on scene, the patient arrested. Upon EMS arrival, she was found apneic and pulseless. Staff stated that she was a DNR patient so EMS stated there was nothing for EMS to do. EMS was about to return to service when the staff stated that the DNR was not valid. Upon inspection, the DNR paperwork had not been completed. It had a physician's signature but absolutely no patient information had been entered in on the DNR form. EMS attempted to contact the next of kin with no success. Staff was also unsuccessful in contacting next of kin. CPR was initiated, patient was found asystole, CPR was started with the Lucas and patient had intravenous attempted, EJ intravenous was unsuccessful, established successfully on patient's left tibia. Intubation performed successfully, asytole/PEA protocol worked per guidelines. Two EPIS and 40 vaso administered. After 3rd round of drugs, patient regained and retained pulse through rest of treatment and transport. Patient was taken to hospital and care transferred to ER staff. Interview on [DATE] at 3:03p.m., CR #1's family member stated she was the resident's POA. She explained upon discharge from hospital the physician had given her forms for out of hospital do not resuscitate with only the physician signature on the form. She said this was in case the family decided on DNR status. CR #1's family member said DNR was not discussed with anyone during the resident's admission to the facility but she handed the staff all the discharge documents including the blank DNR form. She said the resident was full code and she believed the resident did not receive prompt resuscitation from the facility when found unresponsive. Interview on [DATE] at 2:27p.m., RN #1 said he was called by the charge nurse around 1:00a.m. on [DATE] to assess CR #1, who had a change in condition. He said he had completed the resident's admission and checked her vital signs about 7p.m. so he was familiar with the resident's normal condition. RN #1 said upon entering CR #1's room on [DATE] around 1:00a.m., he noted she had a change in condition from when he admitted her. He said her head was slumped down and she was not responding verbally. RN #1 said he called CR #1's responsible party and left messages twice. He said the resident's DNR form had a physician's signature only and the patient's information was not filled in. RN #1 said EMS asked why they were called since CR #1 had a DNR and RN#1 told them the form was invalid. RN #1 said EMS asked to see the form then proceeded to CR #1's room to initiate CPR. Interview on [DATE] at 2:27p.m., LVN #1 said CR #1 was noted on [DATE] around 12 midnight to have difficulty breathing, oxygen saturation was not readable and the resident's pulse was faint. She said she was unable to read the pulse because it was very faint. LVN #1 said she thought she recorded the resident's vital signs during the change in condition. She further stated she was getting paperwork ready for EMS while the supervisor, RN #1, was on the phone with 911. LVN #1 said while she was in CR #1's room she heard someone say I think she gave her last breath. LVN #1 said 911 was pulling up at that time and people were heading down the hall with the crash cart, but EMS had already initiated CPR as the crash cart was brought into the room. LVN #1 was unsure of the resident's code status. She stated she heard RN #1 discussing it. Interview on [DATE] about 2:30p.m., the DON said CR #1 was a full code. The DON stated CR #1 admitted to the facility on [DATE], had a change in condition a couple of hours following admission and staff called 911. The DON said CR #1 did not initially receive CPR because she had a pulse and was breathing. The DON further explained that at the time staff reported the resident stopped breathing 911 arrived and began CPR. The DON said she had evaluated the incident and believed staff did what was expected of them. The DON further said the resident was a full code which should have been clearly identified on her chart on admission but instead the incomplete out of hospital DNR form and hospital records that read No CPR created conflicting information. According to the DON, the facility had no advance directive policy. Facility census listed 113 residents.

Based on interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable mental and physical well-being for one of seven residents (CR #1) reviewed for quality of care. LVN #1 failed to thoroughly and consistently monitor CR #1 following an identified change in condition in order to promptly initiate CPR when CR #1 stopped breathing and had no pulse. CR #1 was a full code but had NO CPR documented on her record, which was misleading to both staff and EMS crew. CR #1 regained pulse after about 30 minutes of resuscitation, was brain dead and later died in the hospital. This failure affected one resident and placed 112 additional residents in the facility at risk of not receiving prompt medical intervention in the event of an emergency, which could lead to a resident being resuscitated or allowed to die without intervention, against their wishes. Findings include: Intake # 4 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] at 12:00p.m. She had the following Diagnoses: [REDACTED]. Further review of this face sheet revealed no advanced directive. Record review of CR #1's admission orders [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's hospital record dated [DATE] revealed no advance directives were completed by the patient. CR #1's code status read CPR - No. Record review of CR #1's out of hospital do-not resuscitate form revealed it was signed by her physician but the rest of the form was blank and CR #1's information was not filled in. Record review of CR#1's nurses' notes dated [DATE] revealed the following: Resident arrived at 12:15p.m., per EMS with two attendants, Resident transported per stretcher into facility. Residents is a [AGE] year old white female, alert to person and able to make simple needs known, resident on oxygen at 54 liters via nasal cannula. Oxygen saturation ,[DATE]% upon arrival. Resident to be on oxygen at 4 liters. [MEDICAL CONDITION] during the night. Resident with a skin tear to right anterior wrist area with a 3cm by 4 cm pink bruise to anterior arm. Dressing intact to right upper arm from IV removal. Resident with dressing to back of the left arm. Medications were called into IPC, OK to continue discharged medications. Record review of CR #1's nurses' notes dated [DATE] at 11:11p.m. revealed the following vital signs: temperature 97.2, respiration - 21, blood pressure ,[DATE], oxygen saturation of 96% and heart rate - 84. Record review of CR #1's nurses' notes dated [DATE] at 1:51a.m., revealed at 12:30a.m., CNA called nurse to the room stating that he wants to change resident but she seems to be having difficulty breathing, Nurse (LVN #1) immediately went to resident's room. Noticed deep labored breathing, resident had [MEDICAL CONDITION] mask firmly clutched in the right hand which was on the side of her leg. [MEDICAL CONDITION] mask replaced on the resident, oxygen saturation checked, unable to register a number, pulse noted, no response to verbal stimuli from staff, Nurse immediately called evening nurse to see if this is a change in resident. Evening nurse immediately stated call 911 due to a major change. Resident was alert and talking during evening shift. Night nurse noticed when passing by the room at 10:35p.m. that the resident was watching television with [MEDICAL CONDITION] machine on. Record review of CR #1's nurses' notes dated [DATE] revealed the following: At 12:25a.m., revealed 911 called for resident to be transported for respiratory distress, call placed to resident's (family member) four times to inform her that there is a change for medical status of (CR #1) and that she might be transported to hospital but there was no response from her. Left message to voice mail. At 12:42a.m., revealed EMS on site, no pulse noted at present, nurse taking crash cart to room but EMS had initiated CPR. At 1:10A.M., revealed EMS leaving with resident to hospital, call placed to resident (family member) again, message left informing her that (family member) is being transported to hospital. MD will be notified that resident was out. Record review of CR #1's EMS report dated [DATE] revealed dispatched to emergency transfer, upon arrival facility staff stated the patient had been altered and that triggered the 911 call. During EMS being dispatched and then going enroute and on scene, the patient arrested. Upon EMS arrival, she was found apneic and pulseless. Staff stated that she was a DNR patient so EMS stated there was nothing for EMS to do. EMS was about to return to service when the staff stated that the DNR was not valid. Upon inspection, the DNR paperwork had not been completed. It had a physician's signature but absolutely no patient information had been entered in on the DNR form. EMS attempted to contact the next of kin with no success. Staff was also unsuccessful in contacting next of kin. CPR was initiated, patient was found asystole, CPR was started with the Lucas and patient had intravenous attempted, EJ intravenous was unsuccessful, established successfully on patient's left tibia. Intubation performed successfully, asytole/PEA protocol worked per guidelines. Two EPIS and 40 vaso administered. After 3rd round of drugs, patient regained and retained pulse through rest of treatment and transport. Patient was taken to hospital and care transferred to ER staff. Interview on [DATE] at 3:03p.m., CR #1's family member stated she was the resident's POA. She explained upon discharge from hospital the physician had given her forms for out of hospital do not resuscitate with only the physician signature on the form. She said this was in case the family decided on DNR status. CR #1's family member said DNR was not discussed with anyone during the resident's admission to the facility but she handed the staff all the discharge documents including the blank DNR form. She said the resident was full code and she believed the resident did not receive prompt resuscitation from the facility when found unresponsive. Interview on [DATE] at 9:49p.m., CNA #1 said he worked the night shift on [DATE]. He stated on [DATE] before 12 midnight he went into CR #1's room to provide incontinent care and noted she did not look well. CNA #1 said he called her by name but she did not respond. He said CR #1's breathing was not peaceful, and she seemed to be struggling for air. CNA #1 did not recall if CR #1 had a [MEDICAL CONDITION] machine but said the resident had oxygen on. CNA #1 said he called the nurse who checked on CR #1 but left the room to find the supervisor who was in the other wing of the facility. He said when the nurse returned to the room with the supervisor they were discussing something about CR #1's documents and records. CNA #1 said he left to continue his rounds and was not told by either charge nurse or the supervisor to stay with CR #1. CNA #1 said he did not know what happened after he left but was told CR #1 was taken to the hospital by the 911 crew. Interview on [DATE] at 2:27p.m., RN #1 said he was the evening shift supervisor on [DATE]. He said he had completed CR #1's admission and checked her vital signs about 7p.m. so he was familiar with the resident's normal condition. He stated after his shift, he handed charge over to LVN #1 then went to the other wing of the facility to do his paper work and finish charting. RN #1 said while he was in the other wing charting, LVN #1 came to him about 12 midnight and asked him to come with her to check on the new admission (CR#1). He stated LVN #1 wanted to know if CR #1's current condition was her normal condition RN #1 had observed during admission. RN #1 said, he went to CR #1's room and found her unresponsive. He stated he immediately told LVN #1 to call 911 because the resident had a major change in condition. RN #1 said when he got to CR #1's room with LVN #1, the resident was alone, with her head slumped down and she was unresponsive. RN #1 further said CR #1's DNR form had a physician's signature only and the patient's information was not filled in. He stated he called the resident's responsible party and left messages twice. RN#1 agreed LVN #1 should not have left CR #1 unattended to find him when she identified a change in condition. He said someone should have consistently monitored CR #1. RN #1 said EMS asked why they were called since CR #1 had a DNR and RN#1 told them the form was invalid. RN #1 said he was begging the 911 crew to please hurry and help the resident because her DNR form was invalid. RN #1 said EMS asked to see the form then proceeded to CR #1's room to initiate CPR. Interview on [DATE] at 2:27p.m., LVN #1 said on [DATE] around 12 midnight CR #1 was noted to have difficulty breathing, oxygen saturation was not readable and the resident's pulse was faint. She said she was unable to read the pulse because it was very faint. LVN #1 said she thought she recorded the resident's vital signs somewhere during the change in condition but was unable to locate them in CR #1's chart. LVN #1 was unsure of the resident's code status, but heard RN #1 discussing it. LVN #1 also said she left CR #1 and went to find RN #1 because she wanted to know if CR #1's current condition was changed from her condition at admission earlier that day. LVN #1 said the aide was with CR #1 when she left the room. She stated when she came back with RN #1 he instructed her to call 911, and she and RN #1 both left the room. She said RN #1 was calling 911 and she was getting CR #1's paper work ready for the 911 crew. LVN #1 did not go back to the resident's bedside, did not monitor her vital signs and did not instruct someone to do so. LVN #1 said while she was in CR #1's room she heard someone say I think she gave her last breath. LVN #1 said 911 was pulling up at that time and people were heading down the hall with the crash cart, but EMS had already initiated CPR as the crash cart was brought into the room. Interview on [DATE] about 2:30p.m., the DON said CR #1 was a full code. The DON stated CR #1 admitted to the facility on [DATE], had a change in condition a couple of hours following admission and staff called 911. The DON said CR #1 did not initially receive CPR because she had a pulse and was breathing. The DON further explained that at the time staff reported the resident had stopped breathing, 911 arrived and began CPR. The DON said she had evaluated the incident and believed staff did what was expected of them. The DON further said the resident was a full code which should have been clearly identified on her chart on admission but instead the incomplete out of hospital DNR form and hospital records that read No CPR created conflicting information. The DON said the EMS report was not accurate because she arrived at the facility while EMS was driving off the facility premises. The DON agreed LVN #1 should not have left CR #1 to find RN #1. She further stated LVN #1 should have known her observation of deep labored breathing, unreadable oxygen saturation and very faint pulse were indications of a significant change in condition necessitating emergency intervention. According to the DON, facility had no advance directive policy. Facility census listed 113 residents.

Based on observation, record review, and interviews the facility failed to implement written policies and procedures that prohibited the neglect of 3 of 21 residents (Resident #117, #25, and #20) reviewed for neglect. The facility failed to ensure residents who had been identified as having a high risk for falls were provided the supervision and interventions to prevent further falls. The facility failed to: *Provide Resident #117, who entered the facility with a fractured wrist from a fall, with bedside mats, close supervision, or diversion activities to reduce further falls. Resident # 117 fell 11 times in 4 months with injuries including a fracture to the arm and a re-[MEDICAL CONDITION]. *Provide Resident #25 with a mattress that was low enough on the bed so side rails were not blocked and could aid in the prevention of the resident from falling out of bed for the second time. Resident #25 fell out of the bed 1-9-2012 and had another fall on 1-10-2012, that resulted in the resident being hospitalized . The resident was then placed on a mattress that was so thick (as high as the side rails) and she fell out of bed again on 4-14-2012. *Provide Resident #20 with assistance and a special mattress to reduce the resident's falls when she attempted to transfer herself. Resident #20 fell on [DATE] which resulted in a fractured right arm. In March 2012, the resident fell 5 times in 4 weeks. Four of these 5 falls occurred between 4 A.M. and 10 A.M. when the resident was trying to get up out of bed or go to the bathroom. The resident had previously been on a toileting program prior to her fractured arm, but since her recovery, had not been reassessed for the toileting program. *Ensure staff were able identify, assess, implement interventions consistently, and supervise residents who had been identified at a high risk for falls. An Immediate Jeopardy (IJ) was identified on 05-11-2012 at 5:20 P.M. The Administrator and Director of Nursing were told of the Immediate Jeopardy condition. While the IJ was removed on 5-16-2012 at 11:15 A.M. the facility remained out of compliance at a scope of pattern and a severity of actual harm that was not an immediate jeopardy due to the facility's need to complete staff training and monitor and evaluate the effectiveness of the corrective actions. These failures affected 3 residents, 2 residents fractured their arms and 1 resident, after two falls, had to be hospitalized due to internal bleeding, physical and mental changes, and placed 115 residents at risk of not receiving the level of supervision they required or the assistive devices needed to help prevent falls or injury. Findings include: Resident #117 Record review of Resident #117's face sheet revealed an admission date of [DATE]. Resident #117 was admitted with [DIAGNOSES REDACTED]. She was admitted with a sling to the right arm due to right wrist fracture. Record review of Resident #117's Initial MDS dated [DATE] revealed the resident had a fall prior to admission and a fracture from a fall in the 6 months prior to admission. Further record review revealed the resident had falls since admission. Record review of Resident #117's Initial MDS dated [DATE] revealed the resident required limited assistance with one person physical assistance with transfers. Resident #117 was not steady and only able to stabilize with human assistance when moving from seated to standing position. Record review of the facility's Resident/Visitor Incident Reports revealed Resident #117 had falls on the following dates: 1/18, two falls on 1/25, 3/11, 3/18, 4/12, 4/14, 4/25, 4/27, and 4/30/12. Record review of Resident #117's Care Plan dated 01/26/2012 revealed the following: Problem/Need: ?Resident has a history of falling ?Uses Spanish speaking staff ?Resident attempts to get out of wheelchair on her own and unable to stand ?Removes seat beat (Velcro) and slaps staff when they reapply - combative behavior ?Noncompliant with staff, refusing to stay at nursing station ?Attempted to get into bed on her own ?Forgetful, combative, noncompliant ?Removes alarms and undresses Approaches: ?Assist resident with one staff member for all ambulation ?Remind resident to ask for assist for all ambulation ?Referral resident for PT (physical therapy) evaluation ?Observe for changes in resident ' s condition that may warrant increased supervision/assistance and notify the physician ?Referral to restorative/rehabilitative nursing program ?Keep bed in lowest position ?Keep call light in reach ?Encourage to wear non-skid shoes/socks when out of bed ?Side rails positioned per protocol ?Keep room/area free of clutter Fall on 1/18/2012 Record review of Incident Investigation Report dated 1/18/2012 revealed the following corrective action: ?Resident is a high risk, alert and oriented x1, doesn't follow command due to Dementia ?Continue to monitor her close to nurse station Record review of Resident #117's Care Plan dated 1/26/2012 revealed the following approaches: ?1/18/12 - Bed alarm in place ?1/18/12 - chair alarm in place, remind to ask for assistance Two Falls on 1/25/2012 Record review of Resident #117's Care Plan dated 1/26/2012 revealed the following approach: ?1/25/12 - redirect from going into room alone Record review of Fall Risk Evaluation dated 1/25/12 revealed Resident #117 had 1-2 falls during the last 90 days. "Consider ENVIRONMENTAL RISK factors in resident's interventions." The total score was 18. A resident who scores a 10 or higher was at risk for falls. Record review of Departmental Notes dated 1/25/12 at 9:43 A.M. revealed "...nurse's aide reported resident was found sitting in an upright position on the floor on side of bed with body alarm attached. ...will continue to observe for any changes." Record review of Departmental Notes dated 1/25/12 at 12:02 P.M. revealed at 11:20 A.M. "Resident was reported sitting on side of bed on the pad on the floor by staff, went down to assess resident she was in her bed ...resident got in the bed by herself. " Record review of Incident Investigation Report dated 1/25/2012 revealed the following information: ?Resident was attempting to get out of bed, bed alarm was intact, tennis shoes were on ?Corrective Action: continue to monitor resident as much as possible, resident placed at nurse station for observation. ?Recommendations/New Interventions: Monitor resident while in room frequently Record review of Investigation Follow-up dated 1/25/2012 at 11:25 A.M. revealed resident was found lying in room on side by bed on floor sitting up on pad by staff. There were no new recommendations/new interventions. Record review of Departmental Notes dated 1/27/2012 at 11:21 A.M. revealed " Late Entry: 1/26/12 resident has new orders ...x-ray to the right forearm and wrist confirmation and to follow-up with ortho ... " Record review of Radiology Report dated 1/27/2012 revealed exam forearm right-2v, right. Results: "Through casting, the right forearm demonstrates a [MEDICAL CONDITION] radius with modest medial and posterior displacement of the distal fracture fragments. Conclusion: casted distal radius fracture with displacement." Record review of Resident #117's Care Plan dated 1/26/2012 and updated on 3/18, 4/12, 4/25, and 4/29 revealed the following new approaches after falls: Fall on 3/18/12 - 3/18/12 check for undone seatbelt and reapply Fall on 4/12/12 - 4/12/12 staff encouraging her to remain at nurses' station to watch TV Fall on 4/14/12 - 4/12/12 will ask staff for assistance Fall on 4/25/12 - 4/25/12 staff will check that chair is locked Fall on 4/27/12 - 4/29/12 Monitor for possible re-fracture of arm, send to ortho for evaluation Record review of Resident #117's Interdisciplinary Care Plan revealed the following: ?Problem dated 4/12/12: Resident has a splint to her wrist, was discontinued and cast to right arm with ace and sling. ?Problem dated: 4/30/12: Fall with renewed fracture to her right arm. Cast applied with ace and sling by ortho. Record review of Departmental Notes dated 4/30/12 at 2:41 P.M. revealed resident with [MEDICAL CONDITION] to right arm, complaint of pain, assessed for pain, administered pain medication ... Record review of Departmental Notes dated 4/30/12 at 3:14 P.M. revealed "...swellings noted to right lower arm. Resident is able to move arm, complain of mild pain when arm is moved ... " Record review of Departmental Notes dated 4/30/12 at 3:29 P.M. revealed " resident was observed sitting on the floor by the door turning off alarm in use on Resident ...new order for x-ray to left lower arm ... " Record review of Investigation follow-up dated 4/30/12 at 4:00 P.M. revealed "...resident reported she fell [DATE] but did not report to anyone. She was able to get up by herself. As today 4/30/12 we noticed swollen arm. Suspect fracture to same old fracture. All interventions in place and resident was able to turn off alarms. " Further record review of Investigation follow-up dated 4/30/12 at 4:00 P.M. revealed recommendations/new interventions were as follows: "...all interventions in place, care plan with responsible party will be held to help resident with new interventions. Responsible party to bring appropriate shoes and recommended to move resident close to nurse station..." Record review of Investigation follow-up dated 4/30/2012 revealed "...resident was observed sitting on the floor by the door attempting to turn off alarm. Resident was not able to verbalize what happened. Recommendations/New interventions were resident instructed to call for help when assistance is needed and bed alarm." Record review of Radiology Report sated 4/30/2012 revealed exam of wrist right-3V right. Results: "...There is a chronic fracture involving distal radius with modes displacement. Modest ulnar positive variance. Conclusion: Chronic wrist fracture as described..." Record review of Departmental Notes dated 4/30/2012 at 11:29 P.M. revealed " x-ray to lower right arm result received and called to the NP (chronic wrist fracture with modest displacement) NP ordered for resident to follow up with ortho ... " Observation on 5/10/2012 at 3:30 P.M. Resident #117 was sitting in wheelchair near East nurses' station. Resident was trying to take seatbelt apart. Resident was speaking in Spanish. Observed a Spanish speaking nurse explained to the resident in Spanish to keep the seatbelt on and asked the resident what was wrong. The resident stated "ba?o" which meant toilet. Interview on 5/10/12 at 3:40 P.M., Resident #117 stated she could speak Spanish and English. Resident stated she fell and hurt her arm. Observation on 5/11/2012 at 10:10 A.M. revealed Resident #117 self-propelling with her feet down the hallway that separated the East and West hallways. The wheelchair alarm was sounding. A CNA walked up and asked the resident if she needed any help. The resident stated she was not sure because she did not know where she was going. Resident #117's room was the last room of East Hallway. Observation on 5/11/2012 at 10:30 A.M. revealed the Maintenance Driver communicating with Resident #117 in Spanish in her room. The resident's room was the last room on the hall which dead ended into fire exit door next to the resident's room. This room was the farthest from the nurses' station. The resident was sitting in a wheelchair, with the bed directly in front of her. She had a cast on her right arm. The Maintenance Driver explained to her how to use the brakes on her wheelchair and how to turn on the call light that was lying on the bed. The Maintenance Driver then assisted the resident to turn the call light on. Interview on 5/11/2012 at 10:40 A.M. the Maintenance Driver stated he was trying to teach the resident to use her legs when propelling the wheelchair, use the wheelchair brakes when stopped and to turn on the call light to get help when she wanted to go to bed. He stated he did not transfer residents he would call the nursing staff. Observation on 5/11/2012 at 10:40 A.M. revealed CNA #2 entered the resident's room. A few minutes later the CNA exited the room and walked to the nurse's station. The resident was observed lying in bed. Partial side rails were in the up position. The call light was in place by her left side. The wheelchair was beside the bed. The bed position was approximately 21 inches from the floor. Observation revealed floor mats folded and leaned against the wall at the foot of the resident's bed. Observation revealed a star on the back of the wheelchair and on the name plate at the door. Observation on 5/11/2012 at 10:42 A.M. in the resident room next to the nurse's station was a resident bed that was approximately 12 inches closer to the floor then Resident #117's bed. This bed was surrounded by mats on the floor. Interview on 5/11/2012 at 10:42 A.M. at the nurse's station CNA #2 stated Resident #117 was on the Falling Star Program which meant she "could fall so staff were to watch her closer." She stated she just put the resident to bed to rest. She stated the resident wears an alarm to alert staff if she tries to get up. When asked if mats were used on the floor beside the bed, CNA #2 said she did not think so. At that time LVN #10, who was sitting beside CNA #2, informed CNA #2 Resident #117 was to have bedside mats. CNA #2 stated she did not see a mat in her room nor did she put one down by the bed. Observation on 5/11/2012 at 10:47 A.M. LVN #10 walked down to Resident #117's room, unfolded the mat that was leaning against the wall and placed it on the floor beside the resident's bed. Interview on 5/11/2012 at 10:50 A.M., LVN #1 stated Resident #117 had a fracture to the right wrist when she was admitted . The resident could comprehend what was said to her. She said Resident #117 would get up and the staff would provide redirection and orient her to the call light. LVN #1 stated the resident could balance herself but at times was unsteady. LVN #1 stated the displacement of the forearm and wrist happened due to falls. LVN #1 stated the facility had tried everything with the resident including: body alarms, bed alarms, chair alarms, instructions on using call light but the resident kept being non-compliant. LVN #1 further stated sometimes the alarms could be heard and could not be heard at other times. She stated any resident that had a lot of falls should have a room closer to the nurses' station to ensure alarms could be heard. Observation on 5/11/2012 at 11:30 A.M. revealed LVN #1 walked to Resident #117's room. LVN #1 turned on the bed alarm. The alarm could barely be heard at the nurses' station through all of the talking and the sound of the television. There were two nurses and two CNAs at the nurses' station during the observation. After a short time, one of the nurses jumped up and stated "that's an alarm, who is it". That same nurse began running down the hall towards Resident #117's room. Observation on 5/11/2012 at 3:10 P.M. revealed CNA #2 wheeled the resident to the TV area near East nurse's station. CNA #2 stated the resident did not want to stay in activities and requested to be taken out. CNA #2 did not lock the resident's wheelchair. The resident began self-propelling towards the hallway where her room was located immediately after the CNA left. Interview on 5/11/2012 at 3:45 P.M., DON stated the Falling Star Program was not a formalized program but a way to let staff know that a resident was at risk for falls. The residents had laminated stars on the back of their wheelchairs, on resident doors, and walkers. DON stated Unit Managers, MDS Coordinators, and she would care plan residents together. The whole team identified what interventions worked and had not worked. DON further stated residents with multiple falls were encouraged to attend activities and/or sit at the nurse's station. There were more visible staff in those areas that could monitor the residents. She attributed Resident #117's falls to noncompliance by the resident and not having much family support. The resident would not ask for assistance and would get up on her own. DON stated she believed the interventions for Resident #117 were working because the resident had not fallen in the past two weeks. Interview on 5/12/2012 at 10:55 A.M., SW stated Resident #117 had been transferred to a local Hospital-geriatric psych unit for evaluation. The resident could be there for 14-21 days for evaluation and monitoring. The facility was unable to meet the needs of the resident was the reason for the transfer. SW stated she believed all interventions were in place for the residents and the interventions were being implemented consistently. SW further stated the facility had looked into changing the resident's room closer to nurse's station but there was no room available. The residents in the rooms closest to nurse's station did not want to change rooms. Those residents' rights of refusal to change room had to be respected. Resident #25 Record review of Resident #25's admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her medical [DIAGNOSES REDACTED]. Record review of Resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. All these medications thin the blood to reduce chances of blood clots which require close monitoring by lab testing blood for Prothombin Times (PT) and International Normalized Ratio (INR) (Ensures Prothombin, clotting tendency of the blood, is the same from lab to lab). Record review of Investigation Follow-up forms dated 1/9/12 revealed Resident #25 was observed on the floor near her bed, and 1/10/12 the resident slid off the wheelchair and was observed on the floor. Type of Injury: not injured/no injury was documented. Continued review revealed documentation on the 24 hour follow-up was the resident was alert and oriented, vital signs were temperature 98.1 pulse 83 respirations 20 and blood pressure was 141/76. Record review of Nurses Notes dated 1/9/12 revealed Resident #25 was observed on the floor near her bed. "..On assessment no external injury was noted but the resident complained of having pain in her back ..." Record review of Nurses Notes dated 1/10/12 revealed Resident #25 was "medicated for a complaint of back pain with positive effect. " Record review of Neurological Evaluation Flow Sheet revealed Resident #25 was assessed from 1/9/12 to 1/10/12 only. Record review of Nurse's Notes dated 1/12/12 revealed " ... resident (#25) was having altered mental status, slow to respond, unable to open her mouth to take her bedtime medication. Temperature 92.2, blood pressure 74/54, pulse 70, and respirations 16 ...sent to hospital." Record review of History and Physical from a local community hospital revealed Resident #25 was admitted to the hospital on [DATE]. The resident was quite sleepy, had mild altered mentation "...the patient was found down and hypotensive (abnormally low blood pressure)..." Record review of Progress Note (from the local community hospital) dated 1/24/2012 revealed "...She (#25) had [MEDICAL CONDITION] secondary to blood loss due to [MEDICATION NAME] toxicity with retroperitoneal (bleeding behind the abdominal cavity) hematoma (buildup of blood in an organ or tissue caused by a break in a blood vessel) ..." Record review Fall Risk Evaluation dated 10/20/11 revealed Resident #25's score was 18; on 1/9/12 score was 22; on 1/11/12 score was 16; and on 1/25/12 score was 14. The form revealed a score of 10 or greater indicated "at risk" for falls. Record review of Investigation Follow-up form dated 4/14/12 revealed Resident #25 was found lying on the floor. Documented on the form was " air mattress very thick, very little siderail above mattress." This was the second fall out of the bed for the resident. The first fall was 1-9-2012 which required the hospital stay due to internal bleeding. Review of Receipt provided by the facility, no date, revealed Resident #25's air mattress was exchanged for a bolster mattress on 4/16/12. Observation on 5/7/12 at 4:00 P.M. revealed Resident #25 was awake and alert. The resident was on her back with the head of her bed elevated. She had a contracture to her left arm, wrist and hand. A feeding was infusing by pump to her gastrostomy tube at 50 milliliters (ml) per hour. The resident had oxygen on at 2 liters per nasal cannula. Bilateral heel protectors were in place on the resident's heels. Interview on 5/11/12 at 10:50 A.M. DON stated residents were to be monitored for injury after a fall for up to 72 hours. Resident #20 Record review of Resident #20's face sheet revealed an admission date of [DATE] and a readmitted [DATE]. Resident #20 was admitted with [DIAGNOSES REDACTED]. Record review of Resident #20's Quarterly MDS dated [DATE] revealed the following: *Cognitive BIM (Brief Interview for Mental status) score was 7 which means moderately impaired *Transfers - self performance, required extensive assistance *Toilet -self, required extensive assistance and one person assistance *Urinary toileting program - No *Bowel and Bladder - always incontinent Record review of Resident #20's Screen for fall risk dated 5/9/11 revealed a score of 18. The residents Screen for fall risk dated 5/13/11 revealed a score of 22. A score of 10 or higher indicated a high risk of falls on these Screens. Record review of Resident #20 s Care Plan dated 2/01/2012 revealed the following: (Date/Topic/Approaches) 8/4/11-History of falls-Remind to ask for assist for all ambulation 12/9/11-Falls-Place on "Falling Stars" program 1/16/12-right arm fracture-additional assistance with ADLs 2/1/12-history of falls-bed alarm, low bed, low air loss bolster mattress, mat on floor 2/21/12-right arm fracture-floor mat at bedside, bed alarm, Re-evaluate, fall 1/15/12 for effectiveness of toileting program 2/21/12-incontinence of urine-assist to bathroom, observe for signs of emotional Distress of incontinence, evaluation of voiding pattern 2/21/12-unable to transfer-extensive assistance with transfers Record review of nurse's note revealed Resident #20 had falls on: 8/24/11, 8/26/11, 9/11/11, 10/4/11, 10/21/11, 10/25/11, 10/31/11, 11/22/11, 12/9/11 and 12/25/11. All falls were prior to fracture of her arm. Record review of incident investigation revealed Resident #20 had falls on: *1/15/12 at 4 AM attempted to go to bathroom, fracture of right wrist, corrective action: offer toileting *3/8/12 at 4 AM attempted to transfer self, corrective action: body alarm for Resident *3/11/12 at 7 AM attempted to transfer self, corrective action: bed low position, bed sensor to bed at all times, call light in reach. *4/12/12 at 10 AM attempted to go to bathroom, bed alarm was not on, corrective action MA 65 mattress (a special mattress) *4/23/12 at 8 AM attempted to transfer self, no apparent injury, no corrective action noted *4/28/12 at 5 PM attempted to transfer self, bed alarm on, floor mat in place, no corrective action noted Record review of the resident's care plan dated 2/01/2012 revealed no indication of added interventions or assessments to reflect 4 of the past 5 falls occurred in early morning hours or when resident was attempting to go to the bathroom. Observation on 5/10/2012 at 12:50 P.M. Resident #20 was sitting in wheelchair in the dining room. She was feeding self. She had a chair alarm on her chair and a lap belt . Resident #20 was later observed self-propelling by scooting the wheelchair around in the TV nursing area and also in activities. Resident was pleasantly confused. Observation on 5/10/12 at 3:00 P.M. Resident #20's room revealed there was an alarm on her low bed and a floor mat next to bed. The mattress on her bed was a regular air mattress and there was not a falling star sign on the wall in her room. Observation 5/11/12 at 4:00 P.M. Resident #20 visiting with a family member. Resident was able to undo the lab belt on the wheelchair when asked to. Interview on 5/11/12 at 10:45 AM, LVN #3 stated Resident #20 was on the falling star program which meant there was a yellow or pink star sticker on the door, a sign with a large yellow star to hang on the wall in the room and a plastic star to attach to the wheelchair. She stated the residents with the stars would be monitored with more frequent rounds. Interview on 5/11/2012 at 10:50 A.M., CNA #5 stated the star on the residents door meant the resident was at risk for falls and staff knew to keep them up out of bed and out of the room more. Interview on 5/11/12 at 11:00 AM, LVN #4 stated after a resident falls the bed was to be put in the lowest position, bed and chair alarms would be used and the resident would be monitored more frequently. She was not sure of any other new interventions used for fall prevention. She stated the care plans were updated in the morning meetings with the DON and the Unit Managers. If a resident had repeated falls she would inform the Unit Manager and put it in the 24 hour report book. The 24 hour report book would be discussed in the morning meetings. Fall assessments on residents were done at times. She stated Resident #20 was not on a toileting program. Interview on 5/11/12 at 3:30 P.M. CNA #7 stated if a resident falls staff would put a star on the resident's door and that would indicate to keep an eye on the resident more frequent, do checks more frequent like every hour and to remind them to use the call light. Observation on 5/12/12 at 12:00 P.M. Resident #20's bed had a new mattress that had a scooped shape. The nurse stated it may not be a MA65 mattress (special mattress) but it did have a scoop and it helped prevent falls. Review of the Policy titled Fall Reduction Program effective date December 1, 2010 revealed "...It is the policy of this facility to make resident safety a priority. This facility has a fall reduction program that will assist in identifying residents that are "at risk" for falls and initiate interventions that will reduce that risk...Procedure...l) Identification a) Residents will be assessed utilizing the Fall Risk Evaluation Form at the following times: (1) Admission to the facility,(2) Quarterly, (3)Annually, (4) Significant Change, (5) After the occurrence of a fall; (b) Residents scoring a "10" or above utilizing the Fall Risk Assessment form will be considered " at risk" for falls..." Review of the facility's Fall Reduction Program dated 6-1-2004 revealed "It is the policy of this facility to make residents safety a priority. This facility has a fall reduction program that will assist in identifying residents that are "at risk" for falls and initiate interventions that will attempt reduce that risk..." Review of the facility's Suggested Interventions- General form, not dated, revealed the following interventions: * Alarming Devices * More frequent visual checks * Consider room placement near nurse's station * Bed in lowest position * low bed * More frequent toileting/incontinence checks * Consider medication effects: [MEDICAL CONDITION], diuretics, cardiacs * Call bell in reach, resident instructed in use * Clear pathways in resident room * Monitor for behaviors that precipitate falls: agitation, increased confusion, restlessness * Offer diversional activities * Pummel or wedge cushions in wheelchairs * Side rail(s) down for residents attempting to get out of bed Interview on 5/15/12 at 9:15 AM, the Administrator stated the facility had a Quality Assurance Committee called CQI (Continuous Quality Improvement). He stated the CQI meet monthly and more frequently if needs were identified. He further stated issues were resolved through action plans. The action plans would be addressed monthly and would be revised as needed until the issue was resolved. He stated the CQI would continuously change the action plan, conduct follow-ups or audits of the issues, and would track and trend the issue until it was resolved. He stated after Resident # 25 had fallen in January 2012, the CQI had developed an action plan to help resolve the issue with [MEDICATION NAME] and Falls. He stated the committee placed interventions of in-servicing staff and monitored it on a monthly basis until the issue was resolved. He further stated he thought the plan was working. The Administrator did not address Residents #117 or #20's falls at this time. Record review of the facility's form Resident Rights, not dated, revealed "...You have the right to be free from abuse, neglect and exploitation." Record review of the facility's Investigative Protocol Abuse Prohibition not dated, revealed "...Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... this facility recognizes the central importance of all regulatory standards which it must meet or exceed and will strive to provide each resident: Quality care and services based on the Golden Rule, Promotion of the resident's fullest potential, Protection from harm, A sense of security..." Review of the facility's policy Abuse, Neglect, and Exploitation dated July 1, 2009 revealed "Policy Statement: Each region shall have in place procedures for the prevention of and handling of abuse, neglect, and exploitation of residents. Systems shall be in place to monitor the facilities' performance in this area..." A plan to remove the immediate jeopardy was accepted on 5-12-12 at 2:10 P.M. and at that time the surveyors began monitoring the plan. The Plan of Action to Remove the Immediate Jeopardy included the following to address the issues surrounding the falls. *Resident #117 was provided one to one supervision until assessed on 5-11-2012 and was identified as at a high risk for falls. The assessment was shared with the physician. The physician ordered the resident be sent to the hospital for testing and treatment. The family was contacted and approved of the transfer. *Resident #25 was reassessed on 5-11-2012 and was identified as at a high risk for falls. The inter disciplinary team at the facility recommended a ( ) Plus Mattress. This mattress was placed on the resident ' s bed on 5-11-2012. Monitoring every hour started on 5-11-2012 and ended on 5/14/2012 at 8:00 A.M. to ensure the mattress was appropriate based on her fall assessment. *Resident #20 was reassessed on 5-11-2012 and was identified as at a high risk for falls. The resident was placed on a low air loss mattress with side bolsters on 5-11-12. Monitoring every hour was completed on 5-14-2012 at 8:00 A.M. to ensure the mattress was appropriate based on her fall assessment. Resident was assessed and placed on a bowel and bladder program on 5-12-2012. The facility performed a 100% assessment of all residents to determine risk level of falling. All residents who scored as high risk on the assessment were placed on the Falling Star Program on 5-11-2012. This program included identification of resident's with high risks for falls along with interventions to help prevent falls. Residents would be evaluated for further interventions based on the frequency and times of falls by 5-12-2012. Interventions would be individualized based on resident's mental and physical capabilities. Interventions would be care planned. All residents who had falls in past 90 days were re-evaluated on 5-12-2012 and were referred to Physical Therapy for evaluation by 5-14-2012 and will be added to the case load as recommended by the assessment. The facility would train two specific Certified Nurse Aides by the Activity Director to provide diversion activities to

Based on observation, record review, and interviews the facility failed to implement written policies and procedures that prohibited the neglect of 3 of 21 residents (Resident # 25, #117, and #20) reviewed for neglect. The facility failed to ensure residents who had been identified as having a high risk for falls were provided the supervision and interventions to prevent further falls. The facility failed to: *Provide Resident #117, who entered the facility with a fractured wrist from a fall, with bedside mats, close supervision, or diversion activities to reduce further falls. Resident #117 fell 11 times in 4 months with injuries including a fracture to the arm and a re-[MEDICAL CONDITION]. *Provide Resident #25 with a mattress that was low enough on the bed so side rails were not blocked and could aid in the prevention of a second fall out of the resident's bed. Resident #25 fell out of the bed 1-9-2012 and out of her wheelchair on 1-10-2012, that resulted in the resident being hospitalized . The resident was then placed on a mattress that was so thick (as high as the side rails) and she fell out of bed again on 4-14-2012. *Provide Resident #20 with assistance and a special mattress to reduce the resident's falls when she attempted to transfer herself. Resident #20 fell on [DATE] which resulted in a fractured right arm. Four out of 5 falls occurred between 4 A.M. and 10 A.M. when the resident was trying to get up out of bed or go to the bathroom. The resident had previously been on the toileting program prior to her fractured arm but since her recovery had not been reassessed for the toileting program. *Ensure staff was trained to identify, assess, implement interventions consistently, and supervise residents who had been identified at a high risk for falls. An Immediate Jeopardy (IJ) was identified on 05/11/12 at 5:20 PM. The Plan to Correct was accepted on 5/12/12 at 2:10 PM and the IJ was removed on 5/16/12 at 11:15 AM. These failures affected 3 residents; 2 residents fractured their arms and 1 resident after two falls had to be hospitalized due to internal bleeding, physical and mental changes, and placed 115 residents at risk of not receiving the level of supervision they required or the assistive devices needed to help prevent falls or injury. Findings include: Record review of the Policy titled Fall Reduction Program effective date December 1, 2010 revealed "...It is the policy of this facility to make resident safety a priority. This facility has a fall reduction program that will assist in identifying residents that are "at risk" for falls and initiate interventions that will reduce that risk...Procedure...l) Identification a) Residents will be assessed utilizing the Fall Risk Evaluation Form at the following times: (1) Admission to the facility,(2) Quarterly, (3)Annually, (4) Significant Change, (5) After the occurrence of a fall; (b) Residents scoring a "10" or above utilizing the Fall Risk Assessment form will be considered " at risk" for falls..." Record review of the facility's form Resident Rights, not date, revealed "...You have the right to be free from abuse, neglect and exploitation." Record review of the facility's Investigative Protocol Abuse Prohibition, no date, revealed "...Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... this facility recognize the central importance of all regulatory standards which it must meet or exceed and will strive to provide each resident: Quality care and services based on the Golden Rule, Promotion of the resident's fullest potential, Protection from harm, A sense of security..." Record review of the facility's policy Abuse, Neglect and Exploitation, dated 7/1/09, revealed "Policy Statement: Each region shall have in place procedures for the prevention of and handling of abuse, neglect and exploitation of residents. Systems shall be in place to monitor the facilities' performance in this area..." Resident #117 Record review of Resident #117's face sheet revealed she was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. She was admitted with a sling to the right arm due to right wrist fracture. Record review of the facility's Resident/Visitor Incident Reports revealed Resident #117 had 11 falls on the following dates: 1/18/12, two falls on 1/25/12, 3/11/12, 3/18/12, 4/12/12, 4/14/12, 4/25/12, 4/27/12, and 4/30/12. Record review of Resident #117's Initial MDS dated [DATE] revealed the following under Section J Health Conditions: ?Resident had a fall last month prior to admission ?Resident had a fall in the last 2-6 months ?Resident had fracture due to a fall in the 6 months prior to admission ?Resident had One fall with no injury Record review of Resident #117's Quarterly MDS dated ,[DATE] revealed the following under Section J Health Conditions: ?Resident had Two or more falls - No injury Record review of Incident Investigation Report dated 1/18/2012 revealed the following corrective action: ?Resident is a high risk, alert and oriented x 1, doesn't follow command due to Dementia ?Continue to monitor her close to nurse station Record review of Fall Risk Evaluation dated 1/25/12 revealed Resident #117 had 1-2 falls during the last 90 days. It read "Consider ENVIRONMENTAL RISK factors in resident's interventions." The total score was 18. A resident who scores a 10 or higher was at risk for falls. Record review of Incident Investigation Report dated 1/25/2012 revealed the following information: ?Resident was attempting to get out of bed, bed alarm was intact, tennis shoes were on ?Corrective Action: continue to monitor resident as much as possible, resident placed at nurse station for observation. ?Recommendations/New Interventions: Monitor resident while in room frequently Record review of Departmental Notes dated 1/25/12 at 9:43 A.M. read "...nurse's aide reported resident was found sitting in an upright position on the floor on side of bed with body alarm attached. ...will continue to observe for any changes." Record review of Investigation Follow-up dated 1/25/2012 at 11:25 A.M. revealed resident was found lying in room on side by bed on floor sitting up on pad by staff. There were no new recommendations/new interventions identified. Record review of Departmental Notes dated 1/25/12 at 12:02 P.M. read "Resident was reported sitting on side of bed on the pad on the floor by staff, went down to assess resident she was in her bed ...resident got in the bed by herself. " Record review of Resident #117 ' s Care Plan dated 01/26/2012 revealed the following: Problem/Need: ?Resident has a history of falling ?Uses Spanish speaking staff ?Resident attempts to get out of wheelchair on her own and unable to stand ?Removes seat beat (Velcro) and slaps staff when they reapply - combative behavior ?Noncompliant with staff, refusing to stay at nursing station ?Attempted to get into bed on her own ?Forgetful, combative, noncompliant ?Removes alarms and undresses Approaches revealed comments concerning the interventions on the dates the resident fell : ?Assist resident with one staff member for all ambulation ?Remind resident to ask for assist for all ambulation ?Referral resident for PT (physical therapy) evaluation ?Observe for changes in resident ' s condition that may warrant increased supervision/assistance and notify the physician ?Referral to restorative/rehabilitative nursing program ?Keep bed in lowest position ?Keep call light in reach ?Encourage to wear non-skid shoes/socks when out of bed ?Side rails positioned per protocol ?Keep room/area free of clutter ?1/18/12 - Bed alarm in place ?1/18/12 - chair alarm in place, remind to ask for assistance ?1/25/12 - redirect from going into room alone ?3/18/12 - check for undone seatbelt and reapply ?4/12/12 - staff encouraging her to remain at nurse ' s station to watch TV ?4/25/12 - Staff will check that chair is locked ?4/29/12 - Monitor for possible re-fracture of arm, send to ortho for evaluation Record review of Departmental Notes dated 1/27/2012 at 11:21 A.M. read " Late Entry: 1/26/12 resident has new orders ...x-ray to the right forearm and wrist confirmation and to follow-up with ortho ... " Record review of Mobile X Radiology Report dated 1/27/2012 revealed exam forearm right-2v, right. Results read "Through casting, the right forearm demonstrates a [MEDICAL CONDITION] radius with modest medial and posterior displacement of the distal fracture fragments. Conclusion: casted distal radius fracture with displacement." Record review of Resident #117's Interdisciplinary Care Plan revealed the following: ?Problem dated 4/12/12: Resident has a splint to her wrist, was discontinued and cast to right arm with ace and sling. ?Problem dated: 4/30/12: Fall with renewed fracture to her right arm. Cast applied with ace and sling by ortho. Record review of Departmental Notes dated 4/30/12 at 11:29 P.M. revealed " x-ray to lower right arm result received and called to the NP (chronic wrist fracture with modest displacement). NP ordered for resident to follow up with ortho ... " Record review of Departmental Notes dated 4/30/12 at 2:41 P.M. revealed observed resident with [MEDICAL CONDITION] to right arm, complaint of pain, assessed for pain, administered pain medication ... Record review of Departmental Notes dated 4/30/12 at 3:14 P.M. revealed " ...swellings noted to right lower arm. Resident is able to move arm, complain of mild pain when arm is moved ... " Record review of Departmental Notes dated 4/30/12 at 3:29 P.M. revealed " resident was observed sitting on the floor by the door turning off alarm in use on Resident ...new order for x-ray to left lower arm ... " Record review of Investigation follow-up dated 4/30/12 at 4:00 P.M. revealed "...resident reported she fell [DATE] but did not report to anyone. She was able to get up by herself. As today 4/30/12 we noticed swollen arm. Suspect fracture to same old fracture. All interventions in place and resident were able to turn off alarms." Further review revealed recommendations/new interventions were as follows: "...all interventions in place, care plan with responsible party will be held to help resident with new interventions. Responsible party to bring appropriate shoes and recommended to move resident close to nurse station..." Record review of Investigation follow-up dated 4/30/2012 revealed "...resident was observed sitting on the floor by the door attempting to turn off alarm. Resident was not able to verbalize what happened. Recommendations/New interventions were resident instructed to call for help when assistance is needed and bed alarm." Record review of Mobile X Radiology Report dated 4/30/2012 revealed exam of wrist right-3V right. Results: "...There is a chronic fracture involving distal radius with modes displacement. Modest ulnar positive variance. Conclusion: Chronic wrist fracture as described..." Observation on 5/10/2012 at 3:30 P.M. Resident #117 was sitting in wheelchair near East nurses' station. Resident was trying to take seatbelt apart. Resident was speaking Spanish. Observed a Spanish speaking nurse explained to the resident in Spanish to keep the seatbelt on and asked the resident what was wrong. The resident stated " ba?o " which meant toilet. Interview on 5/10/12 at 3:40 P.M., Resident #117 stated she could speak Spanish and English. Resident stated she fell and hurt her arm. Observation on 5/11/2012 at 10:10 A.M. revealed Resident #117 self-propelling with her feet down the hallway that separated the East and West hallways. The wheelchair alarm was sounding. A CNA walked up and asked the resident if she needed any help. The resident stated not sure because she did not know where she was going. Resident #117 ' s room was the last room of East Hallway. Observation on 5/11/2012 at 10:30 A.M. revealed the Maintenance Driver communicating with Resident #117 in Spanish in her room. The resident's room was the last room on the hall which dead end into fire exit door next to the resident's room. The resident was setting in a wheelchair, with the bed directly in front of her, with a cast on her right arm. Maintenance Driver explained to her how to use the brakes on her wheelchair and how to turn on the call light. The Maintenance Driver then assisted the resident to turn the call light on. Interview on 5/11/2012 at 10:40 A.M. the Maintenance Driver stated he was trying to teach the resident to use her legs when propelling the wheelchair, use the wheelchair brakes when stopped and to turn on the call light to get help when she wanted to go to bed. He stated he did not transfer residents he would call the nursing staff. Observation on 5/11/2012 at 10:40 A.M. revealed CNA # 2 entered the resident ' s room. A few minutes later the CNA exited the room and walked to the nurse's station. The resident was observed lying in bed. Partial side rails were in the up position. The call light was in place by her left side. The wheelchair was beside the bed. The bed position was not in the lowest position and was observed to be approximately 21 inches from the floor. Observation revealed floor mats folded and leaned against the wall at the foot of the resident's bed. Observation revealed a star on the back of the wheelchair and on the name plate at the door. Interview on 5/11/2012 at 10:42 A.M. CNA #2 stated that Resident #117 was on the Falling Star Program which meant she could fall so staff was to watch her closer. She stated she just put the resident in bed. She stated the resident wears an alarm to alert staff if she tries to get up. When asked if mats were used on the floor beside the bed, CNA #2 said she did not think so. At that time LVN #10, who was sitting beside CNA #2, informed CNA #2 Resident #117 was to have bedside mats. CNA #2 stated she did not see a mat nor put one down. Observation on 5/11/2012 at 10:47 A.M. LVN #10 walked down to Resident #117's room, unfolded the mat that was leaning against the wall and placed it on the floor beside the resident's bed. Interview on 5/11/2012 at 10:50 A.M., LVN #1 stated Resident #117 had a fracture to the right wrist when she was admitted . The resident could comprehend what was said to her. She said Resident #117 would get up and the staff would provide redirection and orient her to the call light. LVN #1 stated the resident could balance herself but at times was unsteady. LVN #1 stated the displacement of the forearm and wrist happened due to falls. LVN #1 stated the facility had tried everything with the resident including: body alarms, bed alarms, chair alarms, instructions on using call light but the resident kept being non-compliant. LVN #1 further stated sometimes she could hear the alarms and sometimes she couldn't because her room was at the end of the hallway. She stated any resident that had a lot of falls should have a room closer to the nurses' station to ensure alarms could be heard. Observation on 5/11/2012 at 3:10 P.M. revealed CNA #2 wheeled Resident #117 to the TV area near East nurse's station. CNA #2 stated the resident did not want to stay in activities and requested to be taken out. CNA #2 did not lock the resident ' s wheelchair. The resident began self-propelling her wheelchair towards the hallway where her room was located. Interview on 5/11/2012 at 3:45 P.M., DON stated the Falling Star Program was not a formalized program but a way to let staff know that a resident was at risk for falls. The residents ' had laminated stars on the back of their wheelchairs, on their doors and walkers. DON stated Unit Managers, MDS Coordinators, and she would care plan residents together. The whole team would identify what interventions worked and had not worked. DON further stated residents with multiple falls were encouraged to attend activities and/or sit at the nurse's station. She stated there was more visible staff in those areas that could monitor the residents. She attributed Resident #117's falls to noncompliance by the resident and not having much family support. The resident would not ask for assistance and would get up on her own. DON stated she believed the interventions for Resident #117 were working because the resident had not fallen in the past two weeks. Interview on 5/12/2012 at 10:55 A.M., SW stated Resident #117 had been transferred to a local Hospital-geriatric psych unit for evaluation. The resident could be there for 14-21 days for evaluation and monitoring. The facility was unable to meet the needs of the resident was the reason for the transfer. The Social Worker stated she believed all interventions were in place for the residents and the interventions were being implemented consistently. The Social Worker further stated the facility had looked into changing the resident ' s room closer to nurse's station but there was no room available. The residents in the rooms closest to nurse's station did not want to change rooms. Those residents' rights of refusal to change room had to be respected. Resident #25 Record review of Resident # 25 ' s admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her medical [DIAGNOSES REDACTED]. Record review of Resident # 25 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 30 mg daily on 1/7/12 to 1/12/12; [MEDICATION NAME] 75 mg daily on 1/1/12 to 1/12/12; [MEDICATION NAME] 5 mg daily on 1/6/12 to 1/8/12, [MEDICATION NAME] 3 mg daily 1/9/12 to 1/12/12. These medications help to reduce the chances of blood clots. Record review of Investigation Follow-up form dated 1/9/12, revealed Resident #25 was observed on the floor near her bed. On 1/10/12, revealed she had slid off the wheelchair and was observed on the floor. Type of Injury: not injured/no injury was documented on the form. The 24 hour follow-up revealed Resident #25 was alert and oriented, vital signs: temperature 98.1, pulse 83, respirations 20, and blood pressure was 141/76. Record review of Neurological Evaluation Flow Sheet revealed Resident #25 was assessed from 1/9/12 to 1/10/12 only. Record review of Nurses Notes, dated 1/9/12, revealed resident #25 was observed on the floor near her bed. " ...On assessment no external injury was noted but the resident complained of having pain in her back ..." Record review of Nurses Notes, dated 1/10/12, revealed Resident #25 was " medicated for a complaint of back pain with positive effect. " Record review of Nurses Notes, dated 1/12/12, revealed " Resident (#25) was having altered mental status, slow to respond, unable to open her mouth to take her bedtime medication. Temperature 92.2, blood pressure 74/54, pulse 70, respirations 16...sent to hospital." Record review of History and Physical (from a local community hospital) revealed resident #25 was admitted to the hospital on [DATE]. The resident was quite sleepy, had mild altered mentation "...the patient was found down and hypotensive (abnormally low blood pressure). ...placed in Intensive Care for Severe [MEDICAL CONDITION] and Hypovolemia (blood disorder consisting of a decrease in volume of circulation blood)." Record review of Progress Notes (from a local community hospital) dated 1/24/2012 read "She had [MEDICAL CONDITION] secondary to blood loss due to [MEDICATION NAME] Toxicity with Retroperitoneal (bleeding behind the abdominal cavity) Hematoma (buildup of blood in an organ or tissue caused by a break in a blood vessel) ..." Record review of Admission Report, no date, revealed Resident #25 was being readmitted (back to the facility) with the primary [DIAGNOSES REDACTED]. Record review of Investigation Follow-up form dated 4/14/12 revealed Resident #25 was found lying on the floor. Documented on the form was " air mattress very thick, very little side rail above mattress." The resident had previously fallen out of the bed on 1/9/2012 and wheelchair on 1/10/2012 which required a hospital stay due to internal bleeding... Record review of Receipt, dated 4/16/12, revealed Resident #25 ' s air mattress was exchanged for a bolster mattress. Observation on 5/7/12 at 4:00 P.M. revealed Resident #25 had a contracture to her left shoulder, elbow, wrist, and fingers. The resident's left arm was held tight against her left side and chest, her wrist was bent and held tight against her arm and body, and her hand was tightly closed. Interview on 5/11/12 at 10:50 AM, DON stated residents were to be monitored for injury after a fall for up to 72 hours. Resident #20 Record review of Resident #20 ' s face sheet revealed an admission date of [DATE] and a readmitted [DATE]. She was admitted with [DIAGNOSES REDACTED]. Record review of Resident #20 ' s Quarterly MDS dated [DATE] revealed the following: *Cognitive BIM (Brief Interview for Mental status) score was 7 which indicated the residents was moderately impaired. *Transfers- required extensive assistance *Toilet use- required extensive assistance and one person assistance *Urinary toileting program - No *Bowel and Bladder - always incontinent Record review of Resident #20's Screen for fall risk dated 5/9/11 revealed a score of 18. The residents Screen for fall risk dated 5/13/11 revealed a score of 22. A score of 10 or higher indicated a high risk of falls on these screens. Record review of Resident #20 s Care Plan revealed the following: (Date-Topic-Approaches) *8/4/11-History of falls-Remind to ask for assist for all ambulation *12/9/11-Falls-Place on " Falling Stars " program *1/16/12-Right arm Fracture (FX) -Additional assistance with ADLs *2/1/12-History of falls-Bed alarm, low bed, low air loss bolster mattress, mat on floor *2/21/12-Right arm FX-Floor mat at bedside, bed alarm, Re-evaluate, fell [DATE], for effectiveness of toileting program *2/21/12-Incontinence of urine-Assist to bathroom, observe for signs of emotional Distress of incontinence, evaluation of voiding pattern *2/21/12-Unable to transfer- Extensive assistance with transfers Record review of nurse ' s note revealed Resident #20 had falls on: 8/24/11, 8/26/11, 9/11/11, 10/4/11, 10/21/11, 10/25/11, 10/31/11, 11/22/11, 12/9/11 and 12/25/11. Record review of incident investigation revealed Resident #20 had falls on: *1/15/12 at 4 AM attempt to go to bathroom, fracture (FX) of right wrist, corrective action: offer toileting *3/8/12 at 4 AM attempt to transfer self, corrective action: body alarm for Resident *3/11/12 at 7 AM attempted to transfer self, corrective action: bed low position, bed sensor to bed at all times, call light in reach. *4/12/12 at 10 AM attempt to go to bathroom, bed alarm was not on, corrective action MA 65 mattress (special mattress) *4/23/12 at 8 AM attempt to transfer self, no apparent injury, no corrective action noted *4/28/12 at 5 PM attempt to transfer self, bed alarm on, floor mat in place, no corrective action noted Record review of Resident #20 ' s Care Plan, no date, revealed no indication of added interventions or assessments to reflect 4 of the past 5 falls that occurred in early morning hours or when resident was attempting to go to the bathroom. Observation on 5/10/2012 at 12:50 P.M. Resident #20 was sitting in wheelchair in the dining room. She was feeding herself. She had a chair alarm attached to the wheelchair and a lap belt. Later observation revealed resident was self-propelling her wheelchair in the TV nursing area and also in activities. Resident was pleasantly confused. Observation on 5/10/12 at 3:00 P.M. Resident #20 ' s room revealed there was an alarm on the low bed and a floor mat next to bed. The mattress was a regular air mattress and there was no falling star sign on the wall in her room. Interview on 5/11/12 at 10:45 AM, LVN #3 stated Resident #20 was on the falling star program which meant there was a yellow or pink star sticker on the door, a sign with a large yellow star to hang on the wall in the room and a plastic star to attach to the wheelchair. She stated the residents with the stars would be monitored more frequently during rounds. Interview on 5/11/2012 at 10:50 A.M., CNA #5 stated the star on the residents door meant the resident was at risk for falls and staff knew to keep them up out of bed and out of the room more. Interview on 5/11/12 at 11:00 AM, LVN # 4 stated after a resident fell , interventions included: bed was to be put in the lowest position, bed and chair alarms would be used, and the resident would be monitored more frequently. She was not sure of any other new interventions used for fall prevention for Resident #20. She stated the care plans were updated in the morning meetings with DON and the Unit Managers. She further stated that if a resident had repeated falls she would inform the Unit Manager and put it in the 24 hour report book. The 24 hour report book would be discussed in the morning meetings. Fall assessments on residents were done at times. She stated Resident #20 was not on a toileting program. Interview on 5/11/12 at 3:30 P.M. CNA # 7 stated if a resident fell staff would put a star on the resident's door and that would indicate to keep an eye on the resident more frequently, do frequent checks every hour, and to remind them to use the call bell. Observation 5/11/12 at 4:00 P.M. Resident #20 was visiting with her daughter. Resident was able to undo the lap belt on the wheelchair when asked to. Observation on 5/12/12 at 12:00 P.M. Resident #20's bed had a new mattress that had a scooped shape. The unidentified nurse stated the mattress had a scoop and it helped to prevent falls. Review of the facility's Fall Reduction Program dated 6-1-2004 revealed "It is the policy of this facility to make residents safety a priority. This facility has a fall reduction program that will assist in identifying residents that are "at risk" for falls and initiate interventions that will attempt to reduce that risk..." Review of the facility's Suggested Interventions- General form, not dated, revealed the following interventions: * Alarming Devices * More frequent visual checks * Consider room placement near nurse's station * Bed in lowest position * low bed * More frequent toileting/incontinence checks * Consider medication effects: [MEDICAL CONDITION], diuretics, cardiac * Call bell in reach, resident instructed in use * Clear pathways in resident room * Monitor for behaviors that precipitate falls: agitation, increased confusion, restlessness * Offer diversional activities * Pummel or wedge cushions in wheelchairs * Side rail(s) down for residents attempting to get out of bed Interview on 5/15/12 at 9:15 AM, Administrator stated the facility had a Quality Assurance Committee called the CQI. He stated the CQI met monthly and more frequently if needs were identified. He further stated issues were resolved through action plans. The action plans would be addressed monthly and would be revised as needed until the issue was resolved. He stated the CQI would continuously change the action plan, conduct follow-ups or audits of the issues, and would track and trend the issue until it was resolved. He stated after Resident # 25 had fallen in January 2012, the CQI had developed an action plan to help resolve the issue with [MEDICATION NAME] and Falls. He stated the committee placed interventions of in-servicing staff and monitored it on a monthly basis until the issues were resolved. He further stated he thought the plan was working. Resident #117 ' s falls were not discussed during the interview. The Plan of Action to Remove the Immediate Jeopardy included the following to address the issues surrounding the falls. *Resident #117 was provided one to one supervision until assessed on 5-11-2012 and was identified as at a high risk for falls. The assessment was shared with the physician. The physician ordered the resident be sent to the hospital for testing and treatment. The family was contacted and approved the transfer. *Resident #25 was reassessed on 5-11-2012 and was identified at high risk for falls. The interdisciplinary team recommended a different mattress. This mattress was placed on the resident's bed on 5-11-2012. Monitoring every hour started on 5-11-2012 and ended on 5/14/2012 at 8:00 A.M. to ensure the mattress was appropriate based on her fall assessment. *Resident #20 was reassessed on 5-11-2012 and was identified at high risk for falls. The resident was placed on a low air loss mattress with side bolsters. Monitoring every hour was completed on 5-14-2012 at 8:00 A.M. to ensure the mattress was appropriate based on her fall assessment. Resident was assessed and placed on a bowel and bladder program on 5-12-2012. The facility performed a 100% assessment of all residents to determine risk level of falling. All residents who scored as high risk on the assessment were placed on the Falling Star Program on 5-11-2012. This program included identification of resident's with high risks for falls along with interventions to help prevent falls. Residents would be evaluated for further interventions based on the frequency and times of falls by 5-12-2012. Interventions would be individualized based on resident's mental and physical capabilities. Interventions would be care planned. All residents who had falls in past 90 days were re-evaluated on 5-12-2012 and were referred to Physical Therapy for evaluation by 5-14-2012 and would be added to the case load as recommended by the assessment. The facility would train two specific Certified Nurse Aides by the Activity Director to provide diversion activities to residents assessed for high risk for falls by 5-14-2012 at 10:00 A.M. The activities would be individualized based on resident's mental/physical abilities and preference. Social Services and Nursing would refer all residents identified regarding behavior concerns for psychiatric consultation recommendation by 5-12-2012. An in-service to all staff on Falls Program began on 5-10-2012 and was completed by 5-14-2012 at 10:00 A.M. In-services were provided to all licensed staff concerning the Fall Reduction Program starting on 5-10-2012 and ending 5-14-2012 at noon. These in-services would include the resident being assessed, identified as a high risk for falls, care plan updated and then a star would be placed on the name plate outside the resident ' s door and on their assistive device (wheelchair or walker). The nurse would then verbally communicate to the interventions to the direct care giver. Assessing nurse would communicate newly identified residents to the oncoming shift. If a fall occurred, the nurse would conduct head to toe assessment and render care as indicated. Nurse would notify the physician and responsible party and document. Nurse would complete an incident report, fall investigation form, and document on the 24 hour report. Falls would be reviewed daily at the administrative (Stand Up ) meeting. Interventions would be evaluated and care plans would be updated. A CQI (continuous quality insurance) subcommittee focused on falls was initiated 5-12-2012 the committee would meet once a month at a minimum. The results of subcommittee would be presented to the CQI committee monthly for recommendations. Staff who had not attended the in-service training would not be allowed to work until training was completed. Proficiency testing by verbal/written testing would be completed by Staff Development Coordinator/designee on all staff concerning the Fall Program and assessing residents, and how to respond to resident incidents. Plan of removal verification: Monitoring of the plan began on 5-12-2012. Resident #117 had been transferred to the hospital where a brain scan was being performed also lab work was being done to check for any infections. On t

Based on observation, interview, and record review, the facility failed to provide care as ordered by the physician and as written in the plan of care for 7 of 21 residents (Resident #25, #29, #61, #9, #91,#38 and #50 ) reviewed for compliance with the written plan of care. The facility failed to: *ensure Resident #25's physician ordered blood clotting times (PT/INR lab tests) were conducted. Resident #25's PT/INR were not checked on 1-9-2012 and 1-11-2012 as ordered and the resident was bleeding internally from a fall requiring her to be hospitalized . *ensure Resident #29's clotting time lab tests were completed as ordered by the physician. Resident #29 had specific orders for blood clotting time to be completed on 3-25-2012 and 12-31-2011 which were not completed. *Clarify physician orders for Resident #61 to ensure accurate dosage of blood thinning medication was received. Resident #61's physician ordered resident's [MEDICATION NAME] dose of 1.5 mg to be changed to a higher dose of 2.0 mg every day. The resident had already received the lower dose of 1.5 mg and three hours later received the entire increased dose of 2.0 mg. An Immediate Jeopardy (IJ) was identified on 05-10-2012 at 10:40 A.M. The Administrator and Director of Nursing were told of the Immediate Jeopardy condition. While the IJ was removed on 5-12-2012 at 2:10 P.M. the facility remained out of compliance at a pattern of actual harm. That was not an immediate jeopardy due to the facility's need to complete staff trainings, monitoring and evaluating the effectiveness of the corrective actions. *ensure Resident #25's physician's orders for the resident's heels to be "off loaded" (elevated) while in bed, received oxygen continuously at 2 liter, and when the resident was in bed that her head of bed was elevated were followed. *ensure Resident #9's CBC (complete blood count) lab test was completed. *ensure Resident #91's physician order for [REDACTED]. *ensure Resident #38's physician's orders to provide the resident with heel protectors, mats beside the bed and to "off load" her heels (elevate heels so not on bed) were followed. *ensure Resident #50's physician's orders to keep her fractured left leg elevated were followed. These failures affected 7 residents, one resident who required treatment in the hospital's Intensive Care Unit where she was diagnosed with [REDACTED]. Findings include: IJ Residents Resident #25 Record review of Resident # 25's admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her medical [DIAGNOSES REDACTED]. Review of Resident #25 ' s Physician Orders dated 1/6/12 revealed: [MEDICATION NAME] 5 mg for 3 days (start today) (Friday, Saturday, Sunday), start [MEDICATION NAME] 3 mg Monday, PT/INR (Prothombin Times (INR) Ensures Prothombin, clotting tendency of the blood, is the same from lab to lab) stat today then PT INR every Monday, Wednesday and Friday, stop [MEDICATION NAME] when INR was greater than 2.0, [MEDICATION NAME] 30 mg twice a day (start today). Review of Resident # 25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 30 mg daily on 1/7/2012 through 1/12/2012; [MEDICATION NAME] 75 mg daily on 1/1/2012 through 1/12/2012; and [MEDICATION NAME] 5 mg daily on 1/6/2012 through 1/8/2012, and [MEDICATION NAME] 3 mg daily 1/9/2012 through 1/12/2012. All of these medications were to reduce chances of blood clots which require close monitoring of PT/INR. Record review of Resident #25's lab report sheets revealed PT/INR results for 1/6/12, 1/26/12 and 1/30/12. Review revealed no PT/INR results for 1/9/12 and 1/11/12 as ordered by the physician. Record review of the resident's nurse's notes dated 1/12/12 revealed " resident was having altered mental status, slow to respond, unable to open her mouth to take her bedtime medication. Temperature 92.2, blood pressure 74/54, pulse 70, respirations 16 " ...sent to hospital. Record review of the resident's History and Physical from a local community hospital revealed the resident was admitted to the hospital on [DATE]. The resident was quite sleepy, had mild altered mentation "...the patient was found down and hypotensive (abnormally low blood pressure) ...the INR was supratherapeutic (above therapeutic range) at 11.99, PTT was 119.9 and placed in Intensive Care for severe [MEDICAL CONDITION] and hypovolemia (blood disorder consisting of a decrease in volume of circulation blood)." Record review of the resident s record revealed a progress note from a local community dated 1/24/2012 "...Impression: #4. [MEDICAL CONDITION] with [MEDICATION NAME] toxicity and #5. [MEDICATION NAME] has been terminated. She will not utilize this at present time. She had [MEDICAL CONDITION] secondary to blood loss due to [MEDICATION NAME] toxicity with retroperitoneal (bleeding behind the abdominal cavity) hematoma (build up of blood in an organ or tissue caused by a break in a blood vessel) ..." Review of the resident's Admission report back into the facility undated revealed the resident was being admitted with the primary [DIAGNOSES REDACTED]. Interview on 5/9/12 at 7:00 P.M. the DON stated there was no means of testing PT and INR in the facility. She said these test must be coordinated with the lab. Interview on 5/9/12 at 7:25 P.M. the DON stated the PT and INR labs were not done for Resident #25. As the interview continued she stated the Unit Managers should be keeping the labs current. Transcribing was the problem. She stated staff needed to check the telephone orders daily. Resident #29 Record review of Resident # 29's admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her medical [DIAGNOSES REDACTED]. Record review of the resident's clinical record revealed Physician's orders dated 12/30/11 for INR in A.M.; on 3/21/12 to repeat INR on 3/25/12; and another physician's order written on 4/2/12 to do an INR on 4/2/12. Record review of the lab report sheets revealed there were no PT/INR results for 12/31/11, 3/25/12 and 4/2/12. Review of the facility form PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flow sheet dated from 2/6/12 to 5/9/12 revealed no PT/INR results for 3/25/12 and 4/2/12 for Resident #29. Interview on 5/9/12 at 5:30 P.M. with LVN #4 stated PT/INR lab tests monitored the clotting of the blood and when a resident was on [MEDICATION NAME] it was important to monitor clotting time. Interview on 5/9/12 at 5:45 P.M. RN #2 stated PT/INR monitors the [MEDICATION NAME] or thinning of the blood. She stated these labs need to be checked when on [MEDICATION NAME]. Interview on 5/9/12 at 6:00 P.M. RN #1 stated PT/INR were labs for [MEDICATION NAME] to look for blood clotting factors. Interview on 5/9/12 at 6:20 P.M. LVN #5 stated PT and INR were labs to do when on [MEDICATION NAME] to check for bleeding. Interview on 5/12/ 2012 at 12:35 P.M. LVN #3, Unit Manager, stated when a Physician ordered labs the charge nurse would send the lab request. She stated with PT/INR tests she had a log book to monitor test were done and results were processed. She stated she checked the lab reports every Monday since the majority of the residents who received [MEDICATION NAME] had PT/INR labs done on Mondays. She stated she checked the lab book every morning for labs ordered. She stated the Nurse Practitioner was here every Monday and Thursday and would check the lab results. LVN#3 stated she picks up all orders written every morning. She stated if the orders were not clear she would contact the nurse to clarify the order. She stated she along with medical records entered the orders into the computer system. Resident #61 Record review of Resident #61's face sheet revealed she was admitted to the facility on [DATE] and was [AGE] years old. She was diagnosed with [REDACTED]. Record review of Resident #61's Physician Orders, dated 4/10/12, read "Increase [MEDICATION NAME] 2 mg PO today, then 1.5 mg PO daily ". Further review of Physician's Orders, dated 4/24/12, read " Increase [MEDICATION NAME] to 2 mg PO (by mouth) daily, INR on 4/30/12" . Further review revealed there was no timestamp identified on the Physician's Order. Record review of CMT/CMA eMAR dated 4/11/12 through 4/23/12, revealed Resident #61 received [MEDICATION NAME] 1.5 mg daily. Further review dated 4/24/12 revealed Resident #61 received [MEDICATION NAME] 1.5 mg at 5:00 PM and an additional dose of [MEDICATION NAME] 2 mg at 8:00 PM. Further review of eMAR, dated 4/25/12 through 4/30/12, revealed she received [MEDICATION NAME] 2 mg daily. Record review of Lab Report revealed Resident #61 had PT/INR labs on 4/23/12 and 4/30/12. On 4/23/12, her PT indicated High with a reading of 19.6 and her INR was Low with 1.5. Lab on 4/30/12 revealed her PT indicated High with a reading of 17.1 and her INR was Low with 1.3. Interview on 5/11/12 at approximately 5:00 PM, DON stated she believed that Resident #61 received [MEDICATION NAME] 3.5 mg because the physician had ordered it that way. She further stated that if there was a question to the Physician's order, the nurse should have called to get a clarification order before administering the medication. While the IJ was removed on 5-12-2012 at 2:10 P.M. the facility remained out of compliance at a scope of pattern and a severity of actual harm. That was not an immediate jeopardy due to the facility's need to complete staff trainings, monitoring and evaluating the effectiveness of the corrective actions. The Plan of Action to Remove the Immediate Jeopardy included the following to address the nine residents receiving blood thinning medications *The Medical Director was notified and Stat PT/INR and CBC ([MEDICATION NAME] (test to assess blood clotting time), International Normalized Ratio (ensures [MEDICATION NAME], clotting tendency of the blood, is the same from lab to lab) and Complete Blood Count) lab tests were obtained on all 9 residents on 5-10-2012. *Vital signs on all 9 residents, every shift for 48 hours and monitoring for signs and symptoms of bleeding started 5-10-2012. *Assessed all residents on blood thinning medication on 5-10-2012 that may have had a witnessed or unwitnessed falls in the past 7 days including neuro vital signs. *Review stat lab results when available for non-therapeutic or toxic results and notify physician for further orders on 5-10-2012. *In-service all nurses and medication aides on anticoagulant labs/assessment starting on the 2-10 P.M. shift 5-10-2012 to be completed by 5-11-2012 that included following physician lab orders, signs and symptoms of [MEDICATION NAME] toxicity and the serious effects of blood thinner medications and the effects it has on residents post falls. * In-service on 5-11-2012 for Certified Nurse Aides on reporting to the nurse any bruises or bleeding noted post fall *Post falls, if a resident was receiving blood thinning medications staff would recommend to the physician to check the resident ' s PT/INR. *Refer all blood thinning medication concerns to the CQI committee on 5-10-2012 then monthly. *Education and ongoing plan regarding Anticoagulants *In-service nurse on following physician lab orders for PT/INR *In-service nurses on transcribing lab orders accurately and timely *In-service nurses and medication aides on monitoring for signs/symptoms of bleeding every shift and document in nurse's notes if bleeding present. Notify physician and responsible party when condition change noted *All licensed staff will be trained to transcribe orders with complete and clear instructions per physician, including updating the MARs and communicating changes. Medication aides will be in-serviced on the verification medication orders before administering *RN, LVN, and Medication Aides in-services will be concluded by 5/11/12. All licensed staff that had not received training will not be allowed to work until training is completed. *Nurses will have pre and post test on Anticoagulant therapy to ensure proficiency. *CNAs will have a check off to help with validation regarding observing residents for signs/symptoms of bruising/bleeding post falls. Plan of removal verification: Monitoring of the plan began on 5-10-2012 when nurses on the 6 A.M.-2 P.M. shift and on 5-11-2012 the 2-6 P.M. shift were interviewed on the in-service topics. The nine resident's lab sheets were reviewed to show stat labs had been conducted with results communicated to the physician on 5-10-2012. Nurses were able to verbalize appropriate transcription of order's procedure, [MEDICATION NAME] Toxicity signs and symptoms, and protocol for assessment and reporting if resident on blood thinning medications fell . Reviewed the in-services provided to CNAs on reporting bruises and any signs of bleeding to the charge nurse. On 5-14-2012 in-service sheets were reviewed and assessed to reveal the majority of the staff had attended the in-services. Also on 5-14-2012, (Monday) the date when most of the nine residents had PT/INR weekly monitoring tests ordered, the resident's documentation revealed that the lab had obtained all ordered specimens except from one resident who refused. That particular resident ' s physician was notified of resident's refusal and order was received to attempt another lab specimen the next day. Surveyors verified on 5-15-2012 all results were received from the lab and staff communicated the results appropriately to the physicians. The survey team determined that the facility had implemented its plan of removal sufficiently to remove the immediate jeopardy, effective 5-12-2012 at 2:10 P.M. The Administrator and Director of Nursing were informed that the immediate jeopardy was lifted. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete staff trainings, monitoring and evaluating the effectiveness of the corrective actions. NON-IJ Residents Resident #25 Record review of the Physician's orders dated May 2012 revealed orders to off load heels at all times while in bed, oxygen at 2 liters per nasal cannula continuously and head of bed elevated at all times. Record review of the resident's care plan dated 7/30/11 updated 3/14/12 titled Activities of Daily Living (ADL) revealed Approaches "...Turn and Position-Resident assisted as needed to turn and repositions at least every 2 hours ..." Observations on 5/8/12 at 8:00 A.M., 10:05 A.M. revealed Resident #25 was awake and alert resting in bed on her back. Both feet were resting on mattress or pillow with bilateral heel protectors on. Oxygen at 2 liters per nasal cannula was on. Observation on 5/8/12 at 10:50 A.M. after wound care the resident was positioned on her back with bilateral heel protectors on.Resident's oxygen was on 2 liters per nasal cannula. Observation on 5/9/12 at 12:00 P.M. revealed the resident sitting in the geri chair in her room with her feet resting on the foot rest, no oxygen was on. The oxygen concentrator was behind the resident's chair and the tubing was on her bed. Interview on 5/10/12 at 9:45 A.M. with RN #1 she stated off-loading means a pillow is under the foot so the heel did not touch the bed, if the heels touched the pillow that was not off loading, wearing heel protectors were alright to wear for an order to off load heels. Observation on 5/10/12 at 2:30 P.M. revealed the resident was up in the geri chair in the common area with visitors without any oxygen. Interview on 5/11/12 at 9:00 A.M. LVN #3 stated continual oxygen should be on all the time. It was not to be taken off. Observation on 5/11/12 at 9:40 A.M. the resident's right heel protector was off leaving her right heel resting on the mattress and her left foot had a heel protector on but foot was directly on the mattress. At 9:44 A.M. the tube feeding was infusing to her [DEVICE] site at 55 ml/hour the head of her bed was laid flat until 9:58 A.M. During the same observation the resident stated she thinks her head needed to stay up. Interview on 5/11/12 at 10:50 A.M. the DON stated if the resident refused her oxygen or if an order was not done it was expected the doctor would be informed the order was unable to be fulfilled. As the interview continued she stated that floated heels meant the legs were positioned on pillows and the heels should not be on the pillow. She stated she was not sure if it was alright to use heel protectors if the heels were to be floated. Interview on 5/11/12 at 10:55 A.M. LVN #4 stated it was alright to put the head of the bed down for a brief time as long as it did not take any longer than 5-10 minutes. There was a risk of aspiration with the head of the bed flat. Observation on 5/12/12 at 10:45 A.M. revealed the resident in bed without her oxygen. Resident #9 Record review of Resident #9's face sheet revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's physician's order for Resident #9 dated 4/2/12 revealed the following order: CBC (complete blood count) in A.M. Record review of Resident #9's nurse's notes dated 4/2/12 at 3:03 P.M. revealed documentation of "CBC ordered by Nurse Practitioner " . Interview and observation on 5/10/12 at 5:00 P.M. revealed LVN #6 was unable to locate lab results in the computer or the resident's medical record. Only documentation LVN #6 located was the nurse's notes of the CBC being ordered on [DATE]. LVN #6 stated the lab should have been done as ordered. Resident # 91 Record review of the face sheet for Resident # 91 revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the resident's Physician's order dated 4/17/12 revealed the following orders: Fresh fruit with breakfast, lunch and dinner Pressure relieving cushion to wheelchair Observation on 5/7/12 at 3:30 P.M. revealed Resident #91 in a wheelchair with no seat cushion. No seat cushion was observed in her room. Observation on 5/8/12 at 11:35 A.M. revealed no fresh fruit on Resident #9's lunch tray. Interview on 5/9/12 at 4:00 P.M. LVN #5, said she was not sure why Resident #91 did not have a cushion for her wheelchair or why there was an order for [REDACTED]. During an interview on 5/9/12 at 5:00 PM Resident #91 stated she had not had fresh fruit with all her meals and she did not have a cushion for her wheelchair. She stated she sat in her wheelchair most of the day and evening everyday. Interview on 5/10/12 at 2:00 P.M. the Dietary Supervisor, stated she did not see a communication order form for Resident #91 to receive fresh fruit for breakfast, lunch and dinner. She stated she had not seen an order like that before but she would order fresh fruit and update Resident #91's diet order in her system. Interview on 5/10/12 at 5:30 P.M. Resident #91 stated she did not know why she was to have fresh fruit with her meals but she liked fruit and she now had a cushion in her wheelchair and it felt much better when she sat in the wheelchair. Resident #38 Record review of Resident #38's clinical record revealed an admission date of [DATE] and with [DIAGNOSES REDACTED]. Record review of physician orders dated 4/29/12 revealed: 1. Bed to be at lowest position on every shift 2. Mat at bed side every shift 3. Bed alarm attached while in bed Record review of physician orders dated 5/7/2012 revealed the following: 1. Air mattress to bed at all times 2. Off load bilateral heels while in bed 3. Heel protectors to bilateral heels while in bed Observation on 5/8/2012 at 8:45 A.M. Resident #38 was lying in bed dressed appropriately. Resident had bilateral heel protectors on and was lying on the air mattress. The mat was rolled up placed in the corner of resident's room. Observation on 5/8/2012 at 3:30 P.M. Resident #38 was lying in bed with bilateral heel protectors on. Both heels were lying on top of a pillow. The mat was not placed next to bedside. Observations on 5/14/2012 at approximately 2:45 P.M. Resident #38 was lying in bed and requested to sit in the wheelchair. Resident did not have bilateral heel protectors on. Two heel protectors were in the resident's chair. There was no mat beside the bed. Interview on 5/9/2012 at approximately 11:15 A.M., LVN #2 stated she was not aware Resident #38 had an order to off load (elevate) her heels. Interview on 5/15/2012 at 8:30 A.M., the DON stated residents that were at a risk for falls should have their beds at the lowest position and mats next to bedside. Some residents had low bed and others had beds that could be lowered. A resident could be identified as a fall risk and not have mats beside the bed if they were ambulatory and if the physician did not order the mats. Resident #50 Record review of Resident #50's face sheet revealed an admission of 6/6/2011 with [DIAGNOSES REDACTED]. Record review of the resident's physician orders dated May 2012 revealed order for staff to keep resident's left leg elevated at all times when in bed. Observation on 5/7/2012 during initial tour revealed Resident #50 lying in bed without immobilizer on. The resident was lying flat and leg was not elevated. Observation on 5/9/2012 at 11:15 A.M. revealed Resident #50 was lying in bed with the head elevated about 30 degrees. The resident had immobilizer on left leg and leg was not elevated. Observation on 5/12/2012 at 11:15 A.M. revealed Resident #50 lying in bed with sitter at bedside. The immobilizer was on left leg and the resident's leg was not elevated. Observation on 5/15/2012 at 1:00 A.M. revealed Resident #50 lying asleep in bed with sitter at bedside. The immobilizer was placed on left leg and leg was not elevated. Interview on 5/15/2012 at 1:00 A.M. CNA #8 stated the immobilizer was on the left leg and no the leg was not elevated. The CNA stated Resident #50 was lying on her left side and on the immobilizer. Review of the facility policy titled Physician Orders,Unable to Follow Effective Date: December 1,2010."...Purpose To ensure that each Attending Physician maintains control of the overall Plan of Care for each resident and has the responsibility for decision making in regard to the plan of care...policy statement...All Physician's Orders shall be followed as prescribed, and if not followed, shall be handled in accordance with the Federal and State Regulations..." CMS Form 672 listed a census of 118.

Based on observation, record review and interviews the facility failed to ensure that 5 of 21 residents (Residents #117, 25, 20, 3 and 5) reviewed for accidents and supervision, were supervised and offered the interventions/assistive devices necessary to prevent further accidents. The facility failed to: *Provide Resident # 117, who entered the facility with a fractured wrist from a fall, with mats, closer supervision, or diversion activities to reduce further falls. Resident # 117 fell 11 times in 4 months with injuries that included a fracture to the arm and a re-fracture to the wrist. *Provide Resident #25 (who had a history of [REDACTED]. Resident #25 fell out of the bed on 1-9-2012 which along with another fall on 1-10-2012, resulted in the resident being hospitalized . The resident was then placed on a mattress that was as high as the side rails and she fell out of bed again on 4-14-2012. *Provide Resident #20 with supervision, a toileting program and a special mattress to reduce the resident's falls when she consistently attempted to transfer herself. Resident #20 fell [DATE] which resulted in a fractured right arm. In March 2012, after becoming more active as the fractured arm healed, the resident fell 5 times in 4 months. Four of these 5 falls occurred between 4 A.M. and 10 A.M. when resident was trying to get up out of bed or go to the bathroom. The resident had been on the toileting program prior to her fractured arm but since her recovery had not been reassessed for the toileting program. An Immediate Jeopardy (IJ) was identified on 05-11-2012 at 5:20 P.M. The Administrator and Director of Nursing were made aware of the Immediate Jeopardy condition. The Administrator and Director of Nursing immediately began working on the plan of action to remove the Immediate Jeopardy. While the IJ was removed on 5-16-2012 at 11:15 A.M. the facility remained out of compliance at a pattern of actual harm that was not an immediate jeopardy due to the facility's need to complete staff trainings, monitor and evaluate the effectiveness of the corrective actions. *Provide Resident #3 with a device to help keep his foot elevated off the floor when he was independently propelling in his wheelchair. *Provide proper storage for Resident #5's oxygen tank. These failures affected 5 residents, 2 residents fractured their arms and 1 resident after two falls had to be hospitalized due to internal bleeding, and placed 113 residents at risk of not receiving the level of supervision they required or the assistive devices they may need to help prevent falls and injury. Findings include: IJ Residents: Resident #117 Record review of Resident #117's face sheet revealed an admission date of [DATE]. Resident #117 was admitted with [DIAGNOSES REDACTED]. She was admitted with a sling to the right arm due to right wrist fracture. Record review of Resident #117's Initial MDS dated [DATE] revealed the resident had a fall prior to admission and a fracture to a fall in the 6 months prior to admission. Further record review revealed the resident had falls since admission. Record review of Resident #117's Initial MDS dated [DATE] revealed the resident required limited assistance with one person physical assistance with transfers. Resident #117 was not steady and only able to stabilize with human assistance when moving from seated to standing position. Record review of the facility's Resident/Visitor Incident Reports revealed Resident #117 had falls on the following dates: 1/18, two falls on 1/25, 3/11, 3/18, 4/12, 4/14, 4/25, 4/27, and 4/30. Record review of Resident #117's Care Plan dated 01/26/2012 revealed the following: Problem/Need ?Resident has a history of falling ?Uses Spanish speaking staff ?Resident attempts to get out of wheelchair on her own and unable to stand ?Removes seat beat (Velcro) and slaps staff when they reapply - combative behavior ?Noncompliant with staff, refusing to stay at nursing station ?Attempted to get into bed on her own ?Forgetful, combative, noncompliant ?Removes alarms and undresses Approaches: ?Assist resident with one staff member for all ambulation ?Remind resident to ask for assist for all ambulation ?Referral resident for PT (physical therapy) evaluation ?Observe for changes in resident's condition that may warrant increased supervision/assistance and notify the physician ?Referral to restorative/rehabilitative nursing program ?Keep bed in lowest position ?Keep call light in reach ?Encourage to wear non-skid shoes/socks when out of bed ?Side rails positioned per protocol ?Keep room/area free of clutter Fall on 1/18/2012 Record review of Incident Investigation Report dated 1/18/2012 revealed the following corrective action: ?Resident is a high risk, alert and oriented x1, doesn't follow command due to Dementia ?Continue to monitor her close to nurse station Record review of Resident #117's Care Plan dated 1/26/2012 revealed the following approaches: ?1/18/12 - Bed alarm in place ?1/18/12 - chair alarm in place, remind to ask for assistance 2 Falls on 1/25/2012 Record review of Resident #117's Care Plan dated 1/26/2012 revealed the following approach: ?1/25/12 - redirect from going into room alone Record review of Fall Risk Evaluation dated 1/25/12 revealed Resident #117 had 1-2 falls during the last 90 days. "Consider ENVIRONMENTAL RISK factors in resident's interventions." The total score was 18. A resident who scores a 10 or higher was at risk for falls. Record review of Departmental Notes dated 1/27/2012 at 11:21 A.M. Role: Nursing revealed "Late Entry: 1/26/12 resident has new orders ...x-ray to the right forearm and wrist confirmation and to follow-up with ortho ... " Record review of Radiology Report dated 1/27/2012 revealed exam forearm right-2v, right. Results: "Through casting, the right forearm demonstrates a fracture of the distal radius with modest medial and posterior displacement of the distal fracture fragments. Conclusion: casted distal radius fracture with displacement." Record review of Resident #117's Care Plan dated 1/26/2012 and updated on 3/18, 4/12, 4/25, and 4/29 revealed the following new approaches after falls: Fall on 3/18/12 - 3/18/12 check for undone seatbelt and reapply Fall on 4/12/12 - 4/12/12 staff encouraging her to remain at nurses' station to watch TV Fall on 4/14/12 - 4/12/12 will ask staff for assistance Fall on 4/25/12 - 4/25/12 staff will check that chair is locked Fall on 4/27/12 - 4/29/12 Monitor for possible re-fracture of arm, send to ortho for evaluation Record review of Resident #117's Interdisciplinary Care Plan revealed the following: ?Problem dated 4/12/12: Resident has a splint to her wrist, was discontinued and cast to right arm with ace and sling. ?Problem dated: 4/30/12: Fall with renewed fracture to her right arm. Cast applied with ace and sling by ortho. Record review of Departmental Notes dated 4/30/12 at 2:41 P.M. revealed observed resident with edema to right arm, complaint of pain, assessed for pain, administered pain medication ... Record review of Departmental Notes dated 4/30/12 at 3:14 P.M. revealed " ...swellings noted to right lower arm. Resident is able to move arm, complain of mild pain when arm is moved ... " Record review of Departmental Notes dated 4/30/12 at 3:29 P.M. revealed "resident was observed sitting on the floor by the door turning off alarm in use on Resident ...new order for x-ray to left lower arm ... " Record review of Departmental Notes dated 4/30/2012 at 11:29 P.M. revealed " x-ray to lower right arm result received and called to the NP (chronic wrist fracture with modest displacement) NP ordered for resident to follow up with ortho ... " Record review of Investigation follow-up dated 4/30/12 at 4:00 P.M. revealed "...resident reported she fell [DATE] but did not report to anyone. She was able to get up by herself. As today 4/30/12 we noticed swollen arm. Suspect fracture to same old fracture. All interventions in place and resident was able to turn off alarms. " Further record review of Investigation follow-up dated 4/30/12 at 4:00 P.M. revealed recommendations/new interventions were as follows: "...all interventions in place, care plan with responsible party will be held to help resident with new interventions. Responsible party to bring appropriate shoes and recommended to move resident close to nurse station..." Record review of Investigation follow-up dated 4/30/2012 revealed "...resident was observed sitting on the floor by the door attempting to turn off alarm. Resident was not able to verbalize what happened. Recommendations/New interventions were resident instructed to call for help when assistance is needed and bed alarm." Record review of Radiology Report sated 4/30/2012 revealed exam of wrist right-3V right. Results: "...There is a chronic fracture involving distal radius with modes displacement. Modest ulnar positive variance. Conclusion: Chronic wrist fracture as described..." Observation on 5/10/2012 at 3:30 P.M. Resident #117 was sitting in wheelchair near East nurses' station. Resident was trying to take seatbelt apart. Resident was speaking in Spanish. Observed a Spanish speaking nurse explained to the resident in Spanish to keep the seatbelt on and asked the resident what was wrong. The resident stated " ba?o " which meant toilet. Interview on 5/10/12 at 3:40 P.M., Resident #117 stated she could speak Spanish and English. Resident stated she fell and hurt her arm. Observation on 5/11/2012 at 10:10 A.M. revealed Resident #117 self-propelling with her feet down the hallway that separates the East and West hallways. The wheelchair alarm was sounding. A CNA walked up and asked the resident if she needed any help. The resident stated not sure because she did not know where she was going. Resident #117 ' s room was the last room of East Hallway. Observation on 5/11/2012 at 10:30 A.M. revealed the Maintenance Driver communicating with Resident #117 in Spanish in her room. The resident's room was the last room on the hall which dead ended into fire exit door next to the resident's room. The resident was setting in a wheelchair, with the bed directly in front of her, with a cast on her right arm. Maintenance Driver explained to her how to use the brakes on her wheelchair and how to turn on the call light lying on the bed. The Maintenance Driver then assisted the resident to turn the call light on. Interview on 5/11/2012 at 10:40 A.M. the Maintenance Driver stated he was trying to teach the resident to use her legs when motivating the wheelchair, use the wheelchair brakes when stopped and to turn on the call light to get help when she wanted to go to bed. He stated he did not transfer residents he would call the nursing staff. Observation on 5/11/2012 at 10:40 A.M. revealed CNA #2 entered the resident's room. A few minutes later the CNA exited the room and walked to the nurse's station. The resident was observed lying in bed. Partial side rails were in the up position. The call light was in place by her left side. The wheelchair was beside the bed. The bed position was approximately 21 inches from the floor. Observation revealed floor mats folded and leaned against the wall at the foot of the resident's bed. Observation revealed a star on the back of the wheelchair and on the name plate at the door. Interview on 5/11/2012 at 10:42 A.M. at the nurse's station CNA #2 stated that Resident #117 was on the Falling Star Program which meant she could fall so staff were to watch her closer. She stated she just put the resident to bed to rest. She stated the resident wears an alarm to alert staff if she tries to get up. When asked if mats were used on the floor beside the bed, CNA #2 said she did not think so. At that time LVN #10, who was sitting beside CNA #2, informed CNA #2 Resident #117 was to have bedside mats. CNA #2 stated she did not see a mat nor put one down. Observation on 5/11/2012 at 10:47 A.M. LVN #10 walked down to Resident #117's room, unfolded the mat that was leaning against the wall and placed it on the floor beside the resident's bed. Interview on 5/11/2012 at 10:50 A.M., LVN #1 stated Resident #117 had a fracture to the right wrist when she was admitted . The resident could comprehend what was said to her. She said Resident #117 would get up and the staff would provide redirection and orient her to the call light. LVN #1 stated the resident could balance herself but at times was unsteady. LVN #1 stated the displacement of the forearm and wrist happened due to falls. LVN #1 stated the facility had tried everything with the resident including: body alarms, bed alarms, chair alarms, instructions on using call light but the resident kept being non-compliant. LVN #1 further stated sometimes you could hear the alarms and sometimes you couldn't. She stated any resident that had a lot of falls should have a room closer to the nurses' station to ensure alarms could be heard. Observation on 5/11/2012 at 11:30 A.M. revealed LVN #1 walked to Resident #117's room. LVN #1 turned on the bed alarm. The alarm could barely be heard at the nurses' station through all of the talking and the sound of the television. There were no nurses and two CNAs at the nurses' station during the observation. After a short time, one of the nurses jumped up and stated "that's an alarm, who is it". That same nurse began running down the hall towards Resident #117's room. Observation on 5/11/2012 at 3:10 P.M. revealed CNA #2 rolled the resident to the TV area near East nurse's station. CNA #2 stated the resident did not want to stay in activities and requested to be taken out. CNA #2 did not lock the resident's wheelchair. The resident began self-propelling towards the hallway where her room was located. Interview on 5/11/2012 at 3:45 P.M., the DON stated the Falling Star Program was not a formalized program but a way to let staff know that a resident was at risk for falls. The residents had laminated stars on the back of their wheelchairs, on resident doors, and walkers. The DON stated Unit Managers, MDS Coordinators, and she would care plan residents together. The whole team identified what interventions worked and had not worked. The CNAs were asked if there were any suggestions for interventions related to falls. The DON further stated residents with multiple falls were encouraged to attend activities and/or sit at the nurse's station. There was more visible staff in those areas that could monitor the residents. She attributed Resident #117's falls to noncompliance by the resident and not having much family support. The resident would not ask for assistance and would get up on her own. The DON stated she believed the interventions for Resident #117 were working because the resident had not fallen in the past two weeks. Interview on 5/12/2012 at 10:55 A.M., SW stated Resident #117 had been transferred to a local Hospital-geriatric psych unit for evaluation. The resident could be there for 14-21 days for evaluation and monitoring. The facility was unable to meet the needs of the resident was the reason for the transfer. SW stated she believed all interventions were in place for the resident and the interventions were being implemented consistently. SW further stated the facility had looked into changing the resident's room closer to nurse's station but there was no room available. The residents in the rooms closest to nurse's station did not want to change rooms. Those residents' rights of refusal to change room had to be respected. Resident #25 Record review of Resident # 25's admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Resident #25 was readmitted to the facility on [DATE]. Her medical [DIAGNOSES REDACTED]. Record review of the resident's Fall Risk Evaluation dated 10/20/11 the score was 18; 1/9/12 the score was 22; 1/11/12 the score was 16 and 1/25/12 the score was 14. The form revealed a score of 10 or greater indicated "at risk" for falls. Record review of Resident #25's quarterly MDS dated [DATE] revealed the resident required extensive assistance of one person for personal hygiene and the resident had impairment on one side of her upper and lower extremity. Record review of the resident's clinical record revealed Investigation Follow-up forms dated 1/9/12 which revealed the resident was observed on the floor near her bed. Record review of the resident's nurses notes dated 1/9/12 revealed the resident was observed on the floor near her bed. "..On assessment no external injury was noted but the resident complained of having pain in her back ..." Record review of the resident's nurses notes dated 1/10/12 revealed the resident slid off the wheelchair and was observed on the floor. Type of Injury: not injured/no injury was documented on the form. Continued review revealed 24 hour follow-up resident was alert and oriented vital signs were temperature 98.1 pulse 83 respirations 20 and blood pressure was 141/76. On the same form in the Corrective Action section revealed corrective action to be taken was, push bed against the wall, a bed alarm and placed mat on floor near bed. Record review of the resident's nurses notes dated 1/10/12 revealed the resident was " medicated for a complaint of back pain with positive effect." Record review of the resident's Admission report undated revealed the resident was being admitted back to the facility with the primary [DIAGNOSES REDACTED]. Record review of the resident's clinical record revealed an Investigation Follow-up form dated 4/14/12 which revealed the resident was found lying on the floor. Documented on the form was " air mattress very thick, very little side rail above mattress." Review of the receipt provided by the facility revealed the resident's air mattress was exchanged for a bolster mattress on 4/16/12. Record review of the facility care plan titled history of falls dated 1/9/12 updated on 1/10/12, 4/14/12, 5/11/12 and 5/13/12. Interventions included: Assist (resident) with one staff member for all transfers Referral (resident) for Physical Therapy (PT) evaluations as needed Observe for changes in (resident's) condition that may warrant increased supervision/assistance and notify the physician Keep call light in reach side rails per protocol Reminded to call for assistance with transfers, floor mat next to bed, bed alarm and monitor every shift Urine to rule out Urinary Tract Infection Bolster air mattress Panacea Original Mattress Every 30 minute room checks Observation on 5/7/12 at 4:00 P.M. revealed the resident with a contracture to her left shoulder, elbow, wrist and fingers. The resident's left arm was held tight against her left side and chest, her wrist was bent and held tight against her arm and body and her hand was tightly closed. Observation on 5/11/12 at 9:40 A.M. revealed the resident was awake and alert. The resident was on her back with the head of her bed slightly elevated. She had a contracture to her left arm, wrist and hand. A tube feeding was infusing by pump to her gastrostomy tube at 50 milliliters (ml) per hour. The resident had oxygen on at 2 liters per nasal cannula. Resident #20 Record review of Resident #20's face sheet revealed an admission date of [DATE] and a readmitted [DATE]. Resident #20 was admitted with [DIAGNOSES REDACTED]. Record review of Resident #20's Quarterly MDS dated [DATE] revealed the following: Cognitive BIM (Brief Interview for Mental status) score was 7 which means moderately impaired Transfers - self performance requires extensive assistance Toilet - self- requires extensive assistance Toilet - support- requires one person assistance Urinary toileting program - No Bowel and Bladder - always incontinent Record review of Resident #20's Screen for fall risk dated 5/9/11 revealed a score of 18. The residents Screen for fall risk dated 5/13/11 revealed a score of 22. A score of 10 or higher indicated a high risk of falls on these Screens. Review of the facility's Suggested Interventions- General form, not dated, revealed the following interventions when a resident had a history of [REDACTED]. * Alarming Devices * More frequent visual checks * Consider room placement near nurse's station * Bed in lowest position * low bed * More frequent toileting/incontinence checks * Consider medication effects: psychotropics, diuretics, cardiacs * Call bell in reach, resident instructed in use * Clear pathways in resident room * Monitor for behaviors that precipitate falls: agitation, increased confusion, restlessness * Offer diversional activities * Pummel or wedge cushions in wheelchairs * Side rail(s) down for residents attempting to get out of bed Record review of Resident #20 s Care Plan dated 2/01/2012 revealed the following: (Date/Topic/Approaches) 8/4/11-History of falls-Remind to ask for assist for all ambulation 12/9/11-Falls-Place on "Falling Stars" program 1/16/12-right arm fracture-additional assistance with ADLs 2/1/12-history of falls-bed alarm, low bed, low air loss bolster mattress, mat on floor 2/21/12-right arm fracture-floor mat at bedside, bed alarm, Re-evaluate, fall 1/15/12 for effectiveness of toileting program 2/21/12-incontinence of urine-assist to bathroom, observe for signs of emotional Distress of incontinence, evaluation of voiding pattern 2/21/12-unable to transfer-extensive assistance with transfers Record review of nurse's note revealed Resident #20 had falls on: 8/24/11, 8/26/11, 9/11/11, 10/4/11, 10/21/11, 10/25/11, 10/31/11, 11/22/11, 12/9/11 and 12/25/11. Record review of incident investigation revealed Resident #20 had falls on: 1/15/12 at 4 AM attempt to go to bathroom, fracture of right wrist, corrective action: offer toileting 3/8/12 at 4 AM attempt to transfer self, corrective action: body alarm for Resident 3/11/12 at 7 AM attempted to transfer self, corrective action: bed low position, bed sensor to bed at all times, call light in reach. 4/12/12 at 10 AM attempt to go to bathroom, bed alarm was not on, corrective action MA 65 mattress (special mattress) 4/23/12 at 8 AM attempt to transfer self, no apparent injury, no corrective action noted 4/28/12 at 5 PM attempt to transfer self, bed alarm on, floor mat in place, no corrective action noted Record review of the resident's care plan 2/1/2012 revealed no indication of added interventions or assessments to reflect 4 of the past 5 falls occurred in early morning hours or when resident was attempting to go to the bathroom. Observation on 5/10/2012 at 12:50 P.M. Resident #20 was sitting in wheelchair in the dining room. She was feeding self. She had a chair alarm on her chair and a lap belt . Observed later resident self-propelling by scooting the wheelchair around in the TV nursing area and also in activities. Resident was pleasantly confused. Observation on 5/10/12 at 3:00 P.M. Resident #20 room. There was an alarm on her low bed and a floor mat next to bed. The mattress on her bed was a regular air mattress and there was not a falling star sign on the wall in her room. Observation 5/11/12 at 4:00 P.M. Resident #20 visiting with daughter. Resident was able to undo the lap belt on the wheelchair when asked to. Observation on 5/12/12 at 12:00 P.M. Resident #20's bed had a new mattress that had a scooped shape. The nurse stated it may be a MA 65 mattress (special mattress) but it did have a scoop and it helped prevent falls. Interview on 5/11/12 at 10:45 AM, LVN #3 stated Resident #20 was on the falling star program which meant there was a yellow or pink star sticker on the door, a sign with a large yellow star to hang on the wall in the room and a plastic star to attach to the wheelchair. She stated the residents with the stars would be monitored with more frequent rounds. Interview on 5/11/2012 at 10:50 A.M., CNA #5 stated the star on the residents door meant the resident was at risk for falls and staff knew to keep them up out of bed and out of the room more. Interview on 5/11/12 at 11:00 AM, LVN #4 stated after a resident falls the bed was to be put in the lowest position, bed and chair alarms would be used and the resident would be monitored more. She was not sure of any other new interventions used for falls prevention. She stated the care plans were updated in the morning meetings with the DON and the Unit Managers. If a resident had repeated falls she would inform the Unit Manager and put it in the 24 hour report book. The 24 hour report book would be discussed in the morning meetings. Fall assessments on residents were done at times. She stated Resident #20 was not on a toileting program. Interview on 5/11/12 at 3:30 P.M. CNA #7 stated if a resident falls staff would put a star on the resident's door and that would indicate to keep an eye on the resident more frequent, do checks more frequent like every hour and to remind them to use the call bell. Review of the facility's Fall Reduction Program dated 6-1-2004 revealed "It is the policy of this facility to make residents safety a priority. This facility has a fall reduction program that will assist in identifying residents that are "at risk" for falls and initiate interventions that will attempt reduce that risk..." Interview on 5/15/12 at 9:15 AM, Administrator stated the facility had a Quality Assurance Committee called the CQI. He stated the CQI meet monthly and more frequently if needs were identified. He further stated issues were resolved through action plans. The action plans would be addressed monthly and would be revised as needed until the issue was resolved. He stated the CQI would continuously change the action plan, conduct follow-ups or audits of the issues, and would track and trend the issue until it was resolved. He stated after Resident # 25 had fallen in January 2012, the CQI had developed an action plan to help resolve the issue with Coumadin and Falls. He stated the committee placed interventions of in-servicing staff and monitored it on a monthly basis until the issue was resolved. He further stated he thought the plan was working. Resident #117's falls were not discussed during the interview. A plan to remove the immediate jeopardy was accepted on 5-12-2012 at 2:10 P.M. and at that time the surveyors began monitoring the plan. The Plan of Action to Remove the Immediate Jeopardy included the following to address the issues surrounding the falls. *Resident #117 was provided one to one supervision until assessed on 5-11-2012 and was identified as at a high risk for falls. The assessment was shared with the physician. The physician ordered the resident be sent to the hospital for testing and treatment. The family was contacted and approved of the transfer. *Resident #25 was reassessed on 5-11-2012 and was identified as at a high risk for falls. The interdisciplinary team at the facility recommended a ( ) Plus Mattress. This mattress was placed on the resident's bed on 5-11-2012. Monitoring every hour started on 5-11-2012 and ended on 5/14/2012 at 8:00 A.M. to ensure the mattress was appropriate based on her fall assessment. *Resident #20 was reassessed on 5-11-2012 and was identified as at a high risk for falls. The resident was place on a low air loss mattress with side bolsters on 5-11-12. Monitoring every hour was completed on 5-14-2012 at 8:00 A.M. to ensure the mattress was appropriate based on her fall assessment. Resident was assessed and placed on a bowel and bladder program on 5-12-2012. The facility performed a 100% assessment of all resident to determine risk level of falling. All residents who scored as high risk on the assessment were placed on the Falling Star Program on 5-11-2012. This program included identification of resident's with high risks for falls along with interventions to help prevent falls. Residents would be evaluated for further interventions based on the frequency and times of falls by 5-12-2012. Interventions would be individualized based on resident's mental and physical capabilities. Interventions would be care planned. All residents who had falls in past 90 days were re-evaluated on 5-12-2012 and were referred to Physical Therapy for evaluation by 5-14-2012 and will be added to the case load as recommended by the assessment. The facility would train two specific Certified Nurse Aides by the Activity Director to provide diversion activities to resident's assessed for high risk for falls by 5-14-2012 at 10:00 A.M. The activities would be individualized based on resident's mental, physical and preference. Social Services and Nursing would refer all residents identified regarding behavior concerns for psychiatric consultation recommendation by 5-12-2012. An in-service to all staff on Falls Program starting on 5-11-2012 and completed by 5-14-2012 at 10:00 A.M. In-services were provided to all licensed staff concerning the Fall Reduction Program starting on 5-11-2012 and ending 5-14-2012 at noon. These in-services would include the resident being assessed, identified as a high risk for falls, care plan updated and then a star would be placed on the name plate outside the resident's door and on their assistive device (wheelchair or walker). The nurse would then verbally communicate to the interventions to the direct care giver. Assessing nurse would communicate newly identified residents to the oncoming shift. If a fall occurred the nurse would conduct head to toe assessment and render care as indicated . Nurse would notify physician and responsible party and document . Nurse would complete the incident report, fall investigation form and document on the 24 hour report. Falls would be reviewed daily at the administrative (Stand Up ) meeting. Interventions would be evaluated and care plans would be updated. A CQI (continuous quality insurance) subcommittee focused on falls was initiated 5-12-2012 the committee would meet once a month at a minimum. The results of subcommittee will be presented to the CQI committee monthly for recommendations Staff who had not attended the in-service training would not be allowed to work until training is completed. Proficiency testing by verbal/written testing will be conducted and completed by Staff Development Coordinator/designee on all staff concerning the Fall Program. Proficiency testing by verbal/written will be conducted and completed by Staff Development Coordinator/designee on all licensed staff concerning assessing residents and how to respond to resident incidents. Plan of removal verification: Monitoring of the plan began on 5-12-2012. Resident #117 had been transferred to the hospital where a brain scan was being performed also lab work was being done to check for any infections. On the 2-6 P.M.shift this same day, various staff was interviewed concerning the falling star programs and the different interventions that could be used on residents who had been assessed for high risk. These interviews were repeated on 5-14-2012 on the day shift, night shift and on 5-15-2012 on the day and night shift. Staff members in dietary, laundry, and maintenance were also interviewed on 5-15-2012. During the monitoring visits the in-service sheets were reviewed to ensure that the majority of the staff had attended the in-services. Nurses were interviewed concerning the frequency of fall risks assessments and the scoring system. Also they were questioned as to what they do once a resident was identified as a high risk for falls. All appropriately answered the questions and demonstrated knowledge of the required assessments and interventions. Staff were observed each monitoring visit on their interactio

Based on observation, record review, and interview the facility failed to ensure medication regimens were monitored to help promote or maintain resident's highest practicable mental, physical, and psychosocial well-being of 3 of 9 residents (#'s 25, 29, and 61) who were reviewed for the monitoring of anticoagulant (blood thinning) medications. The facility failed to: *Assess Resident #25's blood clotting times as ordered by the doctor. Resident #25 had orders to have blood clotting times (PT/INR lab test) checked on 1-9-2012 and 1-11-2012 which were not completed. *Assess Resident #25's blood clotting time and neurological checks after two falls in two days. Resident #25 fell on [DATE] and 1-10-2012 and was transferred to the hospital on 1-12-2012 due to mental status changes and [MEDICAL CONDITION] (low blood pressure). She was found to have been injured during one of the falls and was bleeding internally. The facility did not complete the ordered PT/INR that had been ordered by the doctor for 1-9-2012 and 1-11-2012. *Assess Resident #29's clotting time as ordered by the physician. Resident #29 had specific orders for blood clotting time PT/INRs to be completed on 3-25-2012 and 4-2-12 which were not completed. *Clarify physician orders [REDACTED]. Resident #61's physician ordered [MEDICATION NAME] dose to be changed from 1.5 mg every day to a higher dose of 2.0 mg. The resident had received the lower dose of 1.5 mg already that day and three hours later received the entire increased dose of 2.0 mg. She continued to receive the 2.0 mg every day after. An Immediate Jeopardy (IJ) was identified on 05-10-2012 at 10:40 A.M. The Administrator and Director of Nursing were made aware of the Immediate Jeopardy condition. While the IJ was removed on 5-12-2012 at 2:10 P.M. the facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete staff trainings, monitor and evaluate the effectiveness of the corrective actions. These failures affected 3 residents total, placed 1 residents in the hospital Intensive Care Unit where she was diagnosed with [REDACTED]. Findings include: Resident #25 Record review of Resident # 25's admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her medical [DIAGNOSES REDACTED]. Record review of Resident # 25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 75 mg daily on 1/1/2012 through 1/12/2012; [MEDICATION NAME] 5 mg daily on 1/6/2012 through 1/8/2012; [MEDICATION NAME] 30 mg daily on 1/7/2012 through 1/12/2012; [MEDICATION NAME] 3 mg daily 1/9 through 1/12/2010. Which were all medications to reduce chances of blood clots which require close monitoring of Prothombin Times (PT) and International Normalized Ratio (INR) (Ensures Prothombin, clotting tendency of the blood, is the same from lab to lab). (American Family Physician Journal. 1999 [DATE];59(3):635-646.) (http://www.aafp.org/afp/1999/0201/p635.html) Record review of Resident #25's Physician order [REDACTED]. Record review of Resident #25's lab report sheets revealed PT/INR results for 1/6/12, 1/26/12 and 1/30/12. Review revealed no PT/INR results for 1/9/12 and 1/11/12 as ordered by the physician on 1/6/2012. Record review of the resident's nurse's notes dated 1/12/12 revealed " resident was having altered mental status, slow to respond, unable to open her mouth to take her bedtime medication. Temperature 92.2, blood pressure 74/54, pulse 70, respirations 16...sent to hospital." Record review of the resident's History and Physical from a local community hospital revealed the resident was admitted to the hospital on [DATE]. The resident was quite sleepy, had mild altered mentation "...the patient was found down and hypotensive (abnormally low blood pressure) ...the INR was supratherapeutic (above therapeutic range) at 11.99, PTT was 119.9 and placed in Intensive Care for severe [MEDICAL CONDITION] and hypovolemia (blood disorder consisting of a decrease in volume of circulation blood)." Record review of Progress Note dated 1/24/2012 (from the local community hospital) read "...Impression: #4. [MEDICAL CONDITION] with [MEDICATION NAME] toxicity and #5. [MEDICATION NAME] has been terminated. She will not utilize this at present time. She had [MEDICAL CONDITION] secondary to blood loss due to [MEDICATION NAME] toxicity with retroperitoneal (bleeding behind the abdominal cavity) hematoma (build up of blood in an organ or tissue caused by a break in a blood vessel) ..." Interview on 5/9/12 at 7:00 P.M. DON stated the facility did not have the capability of testing resident's PT/ INR in the facility. She stated these tests must be done by the lab. Interview on 5/9/12 at 7:25 P.M. DON stated the labs were not done for PT and INR for Resident #25. As the interview continued she stated the Unit Managers should be keeping the labs current. Transcribing was the problem. Staff needed to check the telephone orders daily. Resident #29 Review of Resident # 29's admission information revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her medical [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed physician's orders [REDACTED]. Review of the resident's lab report sheets revealed there were no PT/INR results for 12/31/11, 3/25/12 and 4/2/12. Review of the facility form PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) Flow sheet dated from 2/6/12 to 5/9/12 revealed no PT/INR results for Resident #29 for 3/25/12 and 4/2/12. Interview on 5/9/12 at 4:10 P.M. LVN #5 stated when a lab order was received the order was entered into the computer system. The facility system was directly connected to the lab company. The order would automatically be placed on the list for the lab technician. A lab technician came to the facility every Monday - Friday morning or as needed to draw the labs ordered. The lab technician completed a log sheet of the lab draws . When asked how the orders were verified and input into the system correctly she said orders were reviewed by the Unit Managers in the morning meeting. Interview on 5/9/12 at 5:30 P.M. LVN #4 stated PT/INR monitored the clotting of blood and when a resident was on [MEDICATION NAME] it was important to monitor the labs. Interview on 5/9/12 at 5:45 P.M. RN #2 stated PT/INR monitors the [MEDICATION NAME] or thinning of the blood. Labs need to be checked when a resident was taking [MEDICATION NAME]. Interview on 5/9/12 at 6:00 P.M. RN #1 stated PT/INR were labs for [MEDICATION NAME] to look for clotting factors. Interview on 5/12/ 2012 at 12:35 P.M. LVN #3, Unit Manager, stated when a Physician ordered labs the charge nurse would send the lab request. She stated with PT/INR tests she had a log book to monitor test were done and results were processed. She stated she checked the lab reports every Monday since the majority of the residents who received [MEDICATION NAME] had PT/INR labs done on Mondays. She stated she checked the lab book every morning for labs ordered. She stated the Nurse Practitioner was here every Monday and Thursday and would check the lab results. LVN#3 stated she picked up all orders written every morning. If the orders were not clear she would contact the nurse to clarify the order. She stated she along with medical records entered the orders into the computer system. Resident #61 Record review of Resident #61's face sheet revealed she was admitted to the facility on [DATE] and was [AGE] years old. She was diagnosed with [REDACTED]. Record review of Resident #61's CMT/CMA eMAR, dated 3/24/12, read "[MEDICATION NAME] 1 mg tablet by mouth on Tuesday, Wednesday, Thursday, Saturday, and Sunday". Record review of Resident #61's CMT/CMA eMAR, dated 3/26/12, read "[MEDICATION NAME] 1mg tablet, give 1/2 tablet (0.5mg) by mouth on Monday and Friday". Record review of Resident #61's Physician Orders, dated 4/10/12, read " Increase [MEDICATION NAME] 2 mg PO today, then 1.5 mg PO daily " . Further review of physician's orders [REDACTED]. Further review revealed no timestamp was identified on the physician's orders [REDACTED]. Record review of CMT/CMA eMAR, revealed on: 4/11/12 through 4/23/12, she received [MEDICATION NAME] 1.5 mg daily; 4/24/12 revealed Resident #61 received [MEDICATION NAME] 1.5 mg at 5:00 PM and an additional dose of [MEDICATION NAME] 2 mg at 8:00 PM; 4/25/12 through 4/30/12, revealed she received [MEDICATION NAME] 2 mg daily. Review of the resident's lab Report revealed Resident #61 had PT/INR labs on: 4/16/12, PT indicated High with a reading of 16.2 and her INR was Low with 1.2; 4/23/12, PT indicated High with a reading of 19.6 and her INR was Low with 1.5; 4/30/12, PT indicated High with a reading of 17.1 and her INR was Low with 1.3; and 5/9/12, PT indicated High with a reading of 22.2 and her INR was Low with 1.7. Interview on 5/11/12 at approximately 5:00 PM, DON stated she believed that Resident #61 received [MEDICATION NAME] 3.5 mg because the physician had ordered it that way. She further stated that if there was a question to the physician's orders [REDACTED]. Plan to remove immediate jeopardy: A plan to remove the immediate jeopardy was accepted on 5-11-12 at 1:40 P.M. and at that time the surveyors began monitoring the plan. The Plan of Action to Remove the Immediate Jeopardy included the following to address the nine residents receiving blood thinning medications *The Medical Director was notified and Stat PT/INR and CBC ([MEDICATION NAME] (test to assess blood clotting time), International Normalized Ratio (ensures [MEDICATION NAME], clotting tendency of the blood, is the same from lab to lab) and Complete Blood Count) lab tests were obtained on all 9 residents on 5-10-2012. *Vital signs on all 9 residents, every shift for 48 hours and monitoring for signs and symptoms of bleeding started 5-10-2012. *Assessed all residents on blood thinning medication on 5-10-2012 that may have had a witnessed or unwitnessed falls in the past 7 days including neuro vital signs. *Review stat lab results when available for non-therapeutic or toxic results and notify physician for further orders on 5-10-2012. *In-service all nurses and medication aides on anticoagulant labs/assessment starting on the 2-10 P.M. shift 5-10-2012 to be completed by 5-11-2012 that included following physician lab orders, signs and symptoms of [MEDICATION NAME] toxicity and the serious effects of blood thinner medications and the effects it has on residents post falls. * In-service on 5-11-2012 for Certified Nurse Aides on reporting to the nurse any bruises or bleeding noted post fall. *Post falls, if a resident was receiving blood thinning medications staff would recommend to the physician to check the resident's PT/INR. *Refer all blood thinning medication concerns to the CQI committee on 5-10-2012 then monthly Education and ongoing plan regarding Anticoagulants *In-service nurse on following physician lab orders for PT/INR *In-service nurses on transcribing lab orders accurately and timely *In-service nurses and medication aides on monitoring for signs/symptoms of bleeding every shift and document in nurse's notes if bleeding present. Notify physician and responsible party when condition change noted *All licensed staff will be trained to transcribe orders with complete and clear instructions per physician, including updating the MARs and communicating changes. Medication aides will be in-serviced on the verification medication orders before administering *RN, LVN, and Medication Aides in-services will be concluded by 5/11/12. All licensed staff that had not received training will not be allowed to work until training is completed. Nurses will have pre and post test on Anticoagulant therapy to ensure proficiency. CNAs will have a check off to help with validation regarding observing residents for signs/symptoms of bruising/bleeding post falls. Plan of removal verification: Monitoring of the plan began on 5-10-2012 when nurses on the 6 A.M.-2 P.M. shift and on 5-11-2012 the 2-6 P.M. shift were interviewed on the in-service topics. The nine resident's lab sheets were reviewed to show stat labs had been conducted with results communicated to the physician on 5-10-2012. Nurses were able to verbalize appropriate transcription of order's procedure, [MEDICATION NAME] Toxicity signs and symptoms, and protocol for assessment and reporting if resident on blood thinning medications fell . Reviewed the in-services provided to CNAs on reporting bruises and any signs of bleeding to the charge nurse. On 5-14-2012 in-service sheets were reviewed and assessed to reveal the majority of the staff had attended the in-services. Also on 5-14-2012, (Monday) the date when most of the nine residents had PT/INR weekly monitoring tests ordered, the resident's documentation revealed that the lab had obtained all ordered specimens except from one resident who refused. That particular resident's physician was notified of resident's refusal and order was received to attempt another lab specimen the next day. Surveyors verified on 5-15-2012 all results were received from the lab and staff communicated the results appropriately to the physicians. The survey team determined that the facility had implemented its plan of removal sufficiently to remove the immediate jeopardy, effective 5-12-2012 at 2:10 P.M. The Administrator and Director of Nursing were informed that the immediate jeopardy was lifted. The facility remained out of compliance at a pattern of actual harm due the facility's need to complete staff trainings, monitor and evaluate the effectiveness of the corrective actions. The facility DON reported 9 residents were on anticoagulant therapy in the facility.