Every finding on record at Oaks - Bethany Skilled Nursing, The

Based on resident and staff interviews, record review, and review of the facility's policy titled Discharge Planning, the facility failed to ensure a safe and appropriate discharge for one of one sampled (R)(R113). The facility discharged R113 to an environment that was not safe, placing R113 at risk for psychosocial and physical harm.Findings Include:A review of the facility's policy titled, Discharge Planning last revised on 02/24/2025, documented, .The Discharge Summary provides the necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the patient/resident's plan for care after discharge, including but not limited to the following: Discharge Recapitulation of Stay Form. Notice of Discharge will be issued 1 day prior to the discharge date , Matrix Care Continuity of Care Document (CCD)- Reconciliation of all pre-discharge with post discharge medications.Procedure:.7. The Discharge Summary includes the Discharge Recapitulation of Stay Form, CCD, Discharge Summary and a copy of the face sheet. The policy also revealed, the Senior Care Partner, SSD, or Administrators designee provides oversight for the completion of this process and reviews all aspects of care with the patient /resident and patient representative.A review of R113 admissions records revealed that the resident was admitted to the facility on [DATE] and discharged on 12/02/2025 with diagnoses that included: Chronic obstructive pulmonary disease with (acute) exacerbation, essential hypertension and muscle generalized weakness.Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented that R113 had a Brief Interview for Mental Status (BIMS) of 0 indicating severe cognitive impairment.A review of the care plan for R113 revealed the facility failed to identify and address discharge planning needs, including coordination of community resources (services and agencies) necessary to support a safe transition and promote quality of life in the community.A review of the resident notes report for R113 dated 12/02/2025 revealed that the Notice of Medicare Non-Coverage (NOMNC) was received on 11/26/2025 after the Minimum Data Set (MDS) Coordinator had left for the day. The MDS Coordinator was off for the holiday, and the resident was not informed of the last covered day (LCD). On 12/01/2025, R113 left the building at 8:50AM before MDS Coordinator was made aware that he did not receive the NOMNC. MDS Coordinator left the NOMNC in room R113 as he did not return until 11:00PM.Further review of the resident notes report revealed that the patient never received a timely NOMNC prior to discharge.A review of the NOMNC revealed that the coverage ended on 11/28/2025.Review of financial records for R113 revealed that insurance coverage ended on 11/28/2025; however, services continued through 12/02/2025. Charges for 11/29/2025 through 12/01/2025 were written off, indicating a lack of coordination related to coverage status and discharge planning.A telephone interview on 04/29/2026 at 12:04 PM with resident representative (RR) of R113 who stated she was unsure of the circumstances surrounding R113's discharge from the nursing facility. She provided a contact telephone number for R113.A telephone interview on 04/29/2026 at 12:08 PM with R113 revealed he felt he was discharged inappropriately. He reported that he was sitting at the dining table eating breakfast when staff informed him he was being discharged after he finished his meal. He stated he was not aware of the discharge, as no notice had been provided. The resident further reported that he attempted to speak with the Director of Nursing (DON) but was refused a meeting. He stated he then contacted his brother to pick him up, packed his belongings, and waited outside the facility for transportation.Interview on 04/29/2026 at 1:35 PM with the Social Services Director (SSD) revealed she had been employed at the facility for approximately four months. The SSD stated the resident was admitted for rehabilitation services and that the length of stay is determined by the resident's insurance coverage. She further stated that the MDS Coordinator is responsible for completing the NOMNC. The SSD indicated that residents are notified of discharge, and if the resident is difficult to understand, the family is notified instead. She acknowledged that there have been occasions when residents were provided only a one to two day notice of discharge when a five day notice is required. She further stated there have also been instances in which residents were not prepared for discharge due to late notification and therefore remained in the facility past the intended discharge date .Interview on 04/29/2026 at 1:55 PM with MDS Coordinator revealed that R113 was admitted to the facility from the hospital for therapy services. She provided a copy of the NOMNC, which had not been uploaded into the Electronic Health Records (EHR). The document did not contain the resident's signature. She stated it was difficult to locate the resident due to his frequent sign-in and sign-out from the facility. She reported that she left a copy of the NOMNC at the nursing station for staff to obtain the resident's signature; however, the document was not signed. She further stated that upon returning from the holidays on 12/01/2025, she personally presented the NOMNC to the resident; however, no signature was obtained. She confirmed that she did not notify R113 of the NOMNC or provide the discharge notice within the required timeframe to ensure appropriate and timely discharge planning.Interview on 04/29/2026 at 1:55 PM with MDS Coordinator revealed that R113 was admitted to the facility from the hospital for therapy services. She provided a copy of the NOMNC, which had not been uploaded into the EHR. The document did not contain the resident's signature. She stated it was difficult to locate the resident due to his frequent sign-in and sign-out from the facility. She reported that she left a copy of the NOMNC at the nursing station for staff to obtain the resident's signature; however, the document was not signed. She further stated that upon returning from the holidays on 12/01/2025, she personally presented the NOMNC to the resident; however, no signature was obtained. She confirmed that she did not notify R113 of the NOMNC or provide the discharge notice within the required timeframe to ensure appropriate and timely discharge planning.Interview on 04/30/2026 at 1:48 PM with the East Wing Unit Manager revealed that the NOMNC is received by the MDS Coordinator, who is responsible for notifying the resident of the anticipated discharge and obtaining the required resident signature. The MDS Coordinator then forwards the NOMNC to the Social Services Director (SSD), who initiates the discharge process. The East Wing Unit Manager stated she was not aware of the specific incident involving R113. She confirmed that residents should receive a notice of discharge prior to the discharge date to ensure an appropriate and safe discharge process. She further stated that discharge planning includes arrangements such as medications, home health services, or family support, and that failure to complete a proper discharge process may result in residents not receiving necessary services.Interview on 04/30/2026 at 5:42 PM with the Administrator confirmed that the discharge of R113 was inappropriate. She stated it is her expectation that the MDS Coordinator and SSD ensure all residents receive an appropriate discharge that meets facility and state requirements, including a safe discharge to the community or an alternate plan of the resident's choice. She further stated she plans to provide training to staff related to weekend discharge processes to ensure compliance with required discharge planning procedures.

Based on observations, interviews, and review of the facility's policy titled, Oxygen Safety and Storage, it was determined that the facility failed to ensure there were no free standing oxygen cylinder tanks in one of 13 rooms (room [ROOM NUMBER]) on East Hall. This deficient practice has the potential to place residents at risk for accident or injury. Findings Include:A review of the facility policy titled Oxygen Safety and Storage revealed that it is the policy of [Facility Name] to assure that oxygen is administered and stored safely within the healthcare centers or outside storage areas.The Storage section further revealed: 1. Assure that oxygen tanks kept in storage rooms are either chained to the wall or installed on a stable, wheeled dolly or floor stand.Record review of R7 's electronic health record revealed the following diagnoses but not limited to chronic pulmonary obstructive disease and history of pneumonia.Review of R7's admission Minimum Data Set (MDS), dated [DATE], for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitive awareness with little to no periods of confusion. Review of Section O (Special Treatments, Procedures, and Programs) for R7 did not reflect oxygen therapy.Review of R7's physician order does not reflect oxygen therapy.Observations on 04/28/2026 at 4:46 PM, 04/29/2026 at 8:55 AM, and 04/29/2026 at 2:19 PM in room [ROOM NUMBER] East B revealed that a portable oxygen tank was on the floor in the corner of the room next to the bathroom on all three occasions. Interview on 04/30/2026 at 10:12 AM with Assistant Director of Nursing confirmed that oxygen tank was on the floor. She confirmed that she moved the tank because oxygen tanks should not sit on the floor.Interview on 04/30/2026 at 4:33 PM with Director of Health Services revealed that portable oxygen has to be in a holder at all times. Holders are available on back of wheelchairs and with wheels. She admits that therapy was educated about storage of oxygen.Interview on 04/30/2026 at 5:06 PM with Administrator revealed that portable oxygen tanks in a resident's room should be kept in holders.

Based on observation, staff interviews, and review of the facility policy titled Medication Storage in the Healthcare Centers, the facility failed to ensure a medication cart was locked or under direct supervision of authorized staff in an area accessible to residents for one of two wound care carts (West Unit). This deficient practice had the potential to allow resident access to unsecured medications.Findings Include:A review of the facilities policy titled, Medication Storage in Healthcare Centers, revealed that medications and biologicals are stored safely, securely, and properly following manufacturer recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, Certified Medication Assistants, and pharmacy personnel. Under step three procedure the policy reflects that nursing staff and medication aids who administer medications are responsible for the cleaning and organization of medication carts and storage areas.Observation on 04/29/2026 at 11:39 AM revealed that the treatment cart located on the [NAME] One unit was positioned in front of room [ROOM NUMBER] West, unlocked, with the bottom drawer open.Interview with Licensed Practical Nurse (LPN) DD on 04/29/2026 at 11:39 AM revealed that she had been behind the curtain and could not see the cart. She confirmed that the treatment cart was unlocked and the bottom drawer was open. She admitted that the drawer should have been closed and the cart locked.Observation and interview on 04/29/2026 at 2:39 PM of the East Two-unit medication cart with LPN CC revealed that the third and fourth drawers contained a dirt like substance in the back of the cart. One packet of Zofran (nausea medication) was observed loose in the middle drawer and did not have a label with a resident's name. During interview, LPN CC stated she was unsure whom the Zofran belonged to. She admitted that nurses were responsible for cleaning the medication carts.Interview on 04/30/2026 at 4:00 PM with the Pharmacy Consultant revealed that he evaluated the cleanliness of the carts monthly. He stated he wrote a monthly report and informed the nurse when a medication cart needed attention.Interview on 04/30/2026 at 5:59 PM with the Director of Health Services (DHS) revealed that medication carts, including medication and wound carts, were to remain locked at all times when not in use. She stated the carts were to be locked so they were not accessible to unauthorized individuals. She confirmed that nurses were responsible for keeping medication carts clean and free of expired medications.

Based on observations, interviews and facility policy titled Oxygen Administration, the facility failed to regulate and monitor oxygen liter flow rates according to physician orders for one resident (R)(R2) receiving continuous oxygen from a sample of 11 residents. This deficient practice had the potential to place resident R2 at increased risk of respiratory complications.Findings Include:A review of the facility policy titled Oxygen Administration revised 8/2/2023, documented under Policy Statement: It is the policy of PruittHealth Hospice and Healthcare Centers/Veteran Homes to provide Oxygen safely and accurately. and documented under Procedure: 4. Regulate liter flow to ordered/desired flow rate.A review of R2's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/20/2026 revealed Section C (Cognitive Patterns) that R2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Section I (Active Diagnosis) revealed diagnoses including but not all-inclusive of Chronic Obstructive Pulmonary Disease (COPD), acute respiratory failure with hypoxia, anxiety disorder, type two diabetes melitis, heart failure, functional dyspepsia.A review of R2's care plan dated 10/13/2025 revealed that R2 had altered respiratory status/difficulty breathing related to COPD. Interventions included administering oxygen via nasal canula as ordered by the physician, oxygen saturations as ordered, notify MD (medical doctor) of any changes, give patient/resident plenty of time to perform ADL (activities of daily living).A review of the Physician Orders for R2 revealed an order dated 1/29/2026 for oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuous.An observation on 2/3/2026 at 12:55 PM revealed that R2 was wearing oxygen and the oxygen concentrator flow rate was set between four and one-half to five liters per minute. A second observation on 2/4/2026 at 12:10 PM revealed that R2 was wearing oxygen and the oxygen concentrator flow rate was set at five liters per minute.A third observation on 2/5/2026 at 9:50 AM revealed that R2 was wearing oxygen and the oxygen concentrator flow rate was set between four and one-half to five liters per minute. An observation and interview with Licensed Practical Nurse (LPN) HH on 2/5/2026 at 10:10 AM confirmed that the oxygen concentrator flow rate for R2 was set at between four and one-half to five liters per minute. LPN HH stated that staff should make sure residents receive the correct oxygen liters per minute. She stated that R2's flow rate was to be set to 3 liters per minute continuous. LPN HH reported that she did not check his oxygen flow rate this morning and should have checked the flow rate and oxygen saturation level. An interview with the Director of Health Services (DHS) on 2/5/2026 at 2:21 PM confirmed that the nurses should make sure that the right liter flow rates are set per the physician orders on the oxygen concentrator. The DHS confirmed that the oxygen flow rate for R2 was between four and one-half to five liters. The DHS confirmed that Nurses should check oxygen flow rates throughout their shift.

Based on observations, staff interviews, and facility policy titled, Infection Control: Housekeeping Services, the facility failed to ensure residents living area was safe, clean, comfortable, and homelike for one room (room [ROOM NUMBER] West) and two of two shower rooms. Specifically, 4 [NAME] contained trash and a dark brown substance on floor, electrical cord and wall, while the shower rooms exhibited broken and missing tiles, black substance in the corner of the walls and floor and a build-up of soap scum on the shower walls. The deficient practice had the potential to affect patient comfort and safety.Findings include:A review of the facility policy titled, Infection Control: Housekeeping Services, reviewed 7/17/2025 documented, Routine Cleaning Horizontal Surfaces: 1. In patient/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently if spillage or visible soiling occur. In addition, documented under Trash: 1. Trash will be removed from all areas on a specific schedule to prevent spillage and odors. 1. An observation of room [ROOM NUMBER] [NAME] (4W) on 2/3/2026 at 12:55 PM revealed there was trash on the floor between the air conditioner unit and bed.An observation on 2/4/2026 at 9:23 AM revealed trash on the floor. In addition, a dark brown substance was noted on the floor, electrical cord, and wall above the air conditioning unit.An observation on 2/4/2026 at 12:10 PM revealed that trash remains on the floor and the dark brown stains on the floor, electrical cord, and wall.An observation and interview with the Housekeeping Supervisor (HKS) on 2/5/2026 at 9:53 AM of room [ROOM NUMBER]W confirmed that trash and a dark brown substance was on the floor, electrical cord, and wall. The HKS stated housekeeping staff should clean high touch areas, trash, bedside table, light switch, and toilet daily. The HKS confirmed that housekeeping staff should have removed the trash yesterday. An interview with Certified Nursing Assistant (CNA) FF on 2/5/2026 at 10:21 AM revealed that she did not pick up the trash in room [ROOM NUMBER]W. She stated when care was provided to residents in the room, that trash should be checked and removed as needed.An interview with the Administrator on 2/5/2026 at 2:51 PM confirmed that she observed the trash, cups, and dark brown substance on the floor, wall, and electrical cord. The Administrator stated that trash is everyone's responsibility and that the HKS was addressing the dark brown substance.2. An observation on 2/3/2026 at 1:05 PM revealed the East 2 shower room area had broken and missing tiles, black substance in the corner of the walls and floor and a build-up of soap scum on the shower walls.An observation on 2/3/2026 at 1:05 PM revealed the [NAME] Hall [NAME] Garden Wing shower room had missing and broken tiles, dark black substance in the corners of shower area, and buildup of white soap scum on the shower walls.An observation on 2/4/2026 at 09:03 AM revealed the East 2 shower room continued to exhibit broken and missing tiles, black substance in the corner of the walls and floor and a build-up of soap scum on the shower walls.An observation on 2/4/2026 at11:00 AM revealed the [NAME] Hall [NAME] Garden Wing continued to exhibit missing and broken tiles, dark black substance in corners of shower area, and buildup of white soap scum on the shower walls.An observation and interview with Maintenance Director (MD) and HKS on 2/5/2026 at 9:53 AM confirmed there were missing and broken tiles in both East 2 shower room and [NAME] Garden Wing shower rooms. The HKS confirmed there was a dark black substance in the corners of both shower rooms and the buildup of white soap scum in both areas. The HKS stated the showers needed to be cleaned and in addition, the Certified Nursing Assistant (CNA) staff should clean between patients. The HKS stated that she was new and this was the first time seeing the shower rooms.A concurrent observation and interview of the East Wing and [NAME] Garden shower rooms with the Administrator on 2/5/2026 at 2:51 PM confirmed missing and broken tiles, dark black substance, and white soap scum on walls of both shower rooms. The Administrator stated that they should be cleaned daily by housekeeping staff and the CNA staff should clean and disinfect between showers.

Based on record review, staff interviews, and the facility policy titled Care Plans, the facility failed to create and/or implement a person-centered comprehensive care plan for two residents (R) (R2 and R8) from a sample of 11 residents. Specifically, R2 received the incorrect dosage of oxygen according to physician orders and R8 was not care planned for an assessed elopement risk. This deficient practice had the potential to place residents at risk of clinical complications, injury and diminished quality of life.Findings Include: Review of the facility's policy titled, Care Plans revised 7/27/2023, documented under Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan. and documented under admission Comprehensive Plan of Care: 4. The care plan will contain 4 main components. The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. 1. A review of R2's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) that R2 has a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Section I (Active Diagnosis) revealed diagnoses including but not all-inclusive of Chronic Obstructive Pulmonary Disease (COPD), acute respiratory failure with hypoxia, anxiety disorder, type two diabetes melitis, heart failure, and functional dyspepsia. Section O (Special Treatments, Procedures, and Programs) R2 received oxygen therapy during the assessment review period. A review of R2's care plan dated 10/13/2025 revealed that R2 had altered respiratory status/difficulty breathing related to COPD. Interventions included administering oxygen via nasal canula as ordered by the physician, oxygen saturations as ordered, notify MD (medical doctor) of any changes, give patient/resident plenty of time to perform ADL (activities of daily living.) A review of the Physician Orders for R2 revealed an order dated 1/29/2026, for oxygen at 3 liters per minute (LPM) via nasal cannula (NC) continuous. An observation on 2/3/2026 at 12:55 PM revealed that R2 was wearing oxygen and the oxygen concentrator flow rate was set between four and one-half to five liters per minute. A second observation on 2/4/2026 at 12:10 PM revealed that R2 was wearing oxygen and the oxygen concentrator flow rate was set at five liters per minute. A third observation on 2/5/2026 at 9:50 AM revealed that R2 was wearing oxygen and the oxygen concentrator flow rate was set between four and one-half to five liters per minute. An observation and interview with Licensed Practical Nurse (LPN) HH on 2/5/2026 at 10:10 AM confirmed that the oxygen concentrator flow rate for R2 was set at between four and one-half to five liters per minute. LPN HH stated that staff should make sure residents receive the correct oxygen liters per minute. She stated that R2's flow rate was to be set to 3 liters per minute continuous. LPN HH reported that she did not check his oxygen flow rate this morning and should have checked the flow rate and oxygen saturation level. An interview with the Director of Health Services (DHS) on 2/5/2026 at 2:21 PM confirmed that the nurses should make sure that the right liter flow rates are set per the physician orders on the oxygen concentrator. The DHS confirmed that the oxygen flow rate for R2 was between four and one-half to five liters. The DHS confirmed that Nurses should check oxygen flow rates throughout their shift. An interview with MDS Coordinator JJ on 2/5/2026 at 3:17 PM revealed the care plan was for oxygen as order and confirmed that the physician order was for 3 liters per minute continuous. She stated that staff should follow the care plan and physician orders. 2. A review of the Electronic Medical Record (EMR) revealed that R8 was admitted to the facility on [DATE] with diagnoses including but not limited to non-displaced fracture of zone 1 sacrum and Alzheimer's disease. A review of the admission Minimum Data Set (MDS) assessment for R8 with assessment reference date of 1/14/2026, revealed that R8 presented with a Brief Interview for Mental Status (BIMS) score that was not performed due to resident rarely/never being understood. A review of an Elopement Assessment for R8 dated 1/17/2026, documented a score of 17, which indicated high risk for elopement. A review of the care plan for R8 revised 2/4/2026 revealed there was no documented care plan problem to address the assessed elopement risk. Interview on 2/5/2026 at 2:51 PM with the Administrator revealed all residents were assessed for elopement risk as part of an elopement prevention improvement plan. The Administrator confirmed that all residents that were identified as a risk for elopement should have a care plan problem for elopement. Interview with the Minimum Data Set Nurse on 2/5/2026 at 3:01 PM confirmed that all residents identified as a risk for elopement should have a care plan for elopement.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure one out of 20 sampled Residents (R) (RA) was assessed to safely self-administer medications and that unauthorized and unsecured medications were not left at the bedside. This deficient practice placed RA at risk for unsafe medication use and allowed unsecured medications to be accessible to other residents and visitors.Findings include:Review of clinical records revealed RA was admitted to the facility with diagnoses that included, but were not limited to, gastroesophageal reflux disease (GERD), oropharyngeal phase dysphagia, chronic kidney disease, diabetes, hypertension, and atrial fibrillation. Review of the Quarterly MDS assessment dated [DATE] for R14 revealed Section C (Cognitive Patterns), a BIMS score of 12 out of 15 which indicated moderate cognitive impairment.During observations on 7/30/2025 at 10:33 am, 8/6/2025 at 10:46 am and on 8/19/2025 at 12:00 pm, two thick white tablets were observed sitting on RA's overbed table, which was positioned in front of her, while she was lying in bed, in her room. During the observations, RA stated the tablets were for gas relief, and that the nurses had given them to her, and she took them after meals. Review of RA's clinical record revealed a physician's order, dated 6/7/2025, for two, 80 milligram (mg) chewable Gas Relief tablets to be administered four times a day as needed for a diagnosis of GERD.Review of the care plan for RA revealed no evidence that RA was care planned for self-administration of medication or for medications to be kept at bedside.Review of the Self-Administration of Medication evaluation form dated 6/10/2025 revealed that RA was assessed as not wanting to self-administer medications and that staff would give medications.Following the observation on 8/19/2025 at 12:00 pm of medication in RA's room, Licensed Practical Nurse (LPN) BB was interviewed and observed the medication in RA's room at 12:10 pm. She confirmed the medication was Gas Relief tablets and stated that she had not given any Gas Relief tablets to RA that day. LPN BB stated that she only gave them to RA when she asked, and that she did not ever leave any medication in the room.During an interview on 8/19/2025 at 3:00 pm the Director of Health Services (DHS) confirmed that the medication should not have been left in RA's room.

Based on observations, staff interviews, and record reviews, the facility failed to ensure that the care plan intervention of a floor mat at bedside was implemented for one out of 20 sampled residents (R) (R8). The deficient practice placed R8 at risk for safety and injury.Findings include:Review of clinical records revealed R8 was admitted to the facility with diagnoses that included dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R8 revealed Section B (Hearing, Speech, Vision) indicated highly impaired vision, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) indicated the need for assistance with Activities of Daily Living (ADL) care.Review of progress notes for R8 dated 6/25/2025 at 2:43 pm revealed, a nurse note entry that documented R8's roommate reported that the resident was on the floor. R8 was observed lying on her back on the right side of the bed, near the air conditioner unit. An abrasion was noted to her forehead. The nurse note entry also documented that neurological checks were initiated and were within normal limits, with R8 being alert, oriented to person and confused as per usual for the resident. A floor mat was placed on the floor at bedside to prevent further occurrences.Review of the care plan with problem start date of 4/7/2020 revealed R8 was at risk for falls related to impaired mobility, weakness, cognitive deficits, impaired vision, and psychotropic medication use. Following the fall on 6/25/2025, the fall risk care plan was updated to include an intervention of a fall mat to bedside, dated 6/25/2025.During observations on 8/14/2025 at 2:27 pm, 8/18/2025 at 1:18 pm, and 8/19/2025 at 12:15 pm, R8 was lying in bed, in her room. There was no fall mat on the floor on either side of her bed, as care planned.During an interview on 8/19/2025 at 2:10 pm, when questioned about whose responsibility it was to implement a new intervention following a fall, the Administrator responded that it could be any one of the staff, but it would be the unit manager's responsibility. Cross reference to F689

Based on observations, staff and resident interviews, and record review, the facility failed to ensure that a floor mat was in place for one out of 20 sampled Residents (R) (R8), as a fall intervention. The deficient practice created a potential risk for safety and injury for the resident. Findings include:Review of clinical records revealed R8 was admitted to the facility with diagnoses that included dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R8 revealed Section B (Hearing, Speech, Vision) indicated highly impaired vision, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) indicated the need for assistance with Activities of Daily Living (ADL) care.Review of progress notes for R8 dated 6/25/2025 at 2:43 pm revealed, a nurse note entry that documented R8's roommate reported that the resident was on the floor. R8 was observed lying on her back on the right side of the bed, near the air conditioner unit. An abrasion was noted to her forehead. The nurse note entry also documented that neurological checks were initiated and were within normal limits, with R8 being alert, oriented to person and confused as per usual for the resident. A floor mat was placed on the floor at bedside to prevent further occurrences.Further review of progress notes for R8 dated 6/26/2025 revealed, a Patient at Risk (PAR) note entry that documented the interdisciplinary team (IDT) met and reviewed R8's recent fall. The PAR note included that a fall mat was placed at the bedside to reduce the risk of injury related to falls.However, during observations on 8/14/2025 at 2:27 pm, 8/18/2025 at 1:18 pm, and 8/19/2025 at 12:15 pm, R8 was lying in bed, in her room, with no fall mats on the floor on either side of her bed.During an interview on 8/19/2025 at 2:33 pm, the Director of Health Services (DHS) stated that R8's fall mat was in her room, but it was behind the chair. The DHS stated that the housekeeper may have forgotten to put it back down after she cleaned the room. Cross Reference to F656

Based on observations, staff interviews, and review of the facility policies titled, Labeling, dating, and Storage, Dietary Partner Hygiene and Dress Code, and Cleaning Schedule policy, the facility failed to label and date food items, wear hair coverings appropriately, and ensure fans in the kitchen are free of dust, dirt, and debris. This deficient practice had the potential to effect 89 out of 96 residents receiving an oral diet. Findings include: Review of the facility policy titled Labeling, dating, and storage, revised on 11/11/2022 revealed under Procedure: 1. Food and beverage items will have an identifying label as well as received date and opened date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. Review of facility policy titled Dietary Partner Hygiene and Dress Code revised on 11/10/2020 revealed, Hygiene: 1. Hair is covered with hair net and/or cap. Review of the facility policy titled Cleaning Schedule Policy revised on 9/29/2022 revealed Procedure: Fans: Clean-remove all dust and debris. Observation and Interview on 3/3/2025 at 12:25 pm during the initial kitchen tour with [NAME] AA revealed, the following concerns identified during the tour: -A package of cheese not labeled or dated. -A bag of diced ham not labeled or dated. -Two dietary aids not wearing hair coverings appropriately. Dietary Aid BB was observed to have her scalp covered but her lochs were outside of the hairnet. Dietary Aid CC had her hair tied up into a bun. Only the bun was covered with a hair covering, exposing her entire scalp. -A fan mounted above the dish room that was turned on revealed dirt, dust, and grime on the blades and the fan itself. Interview during this time with [NAME] AA confirmed the bag of diced ham and package of cheese were not labeled or dated. She revealed all staff are responsible for labeling and dating food items. She said if they were not labeled or dated there would be no way of knowing when to discard the item potentially causing illness. Observation on 3/4/2025 at 12:49 pm revealed Dietary Aid CC with her hair tied up into a bun with only the bun covered with a hair cover, exposing her scalp. Interview on 3/4/2025 at 12:50 pm with the Dietary Manager revealed she was aware this surveyor identified a bag of diced ham, and a block of cheese not labeled or dated. She said all staff are responsible for labeling and dating food items. She said her expectations were that staff label and date food items to prevent foodborne illness. Surveyor showed her pictures of her findings, and she verified that they should have been labeled or dated. She also was aware that two dietary aids did not have their heads of hair completely covered with a hair covering and a working fan mounted over the dish room was covered in dirt, dust, and grime. (picture of fan was shown) She revealed she was doing training with all dietary staff about labeling and dating food and wearing hair coverings appropriately. She revealed she had noticed the fan and had just cleaned it. She confirmed hair coverings should be worn over all hair for sanitation purposes and that fans should be clean, so they do not blow dust onto food or dishes.

Based on observations, record review, and interviews, the facility failed to maintain a safe and homelike environment on three of seven halls (E3, E4, and [NAME] wing hall) and in the laundry room. Specifically, the shower room on E3 hall had broken wall tiles; Resident (R) (R19) on E4 hall privacy curtain was stained with a brown substance and motorized wheelchair had a build-up of brownish-black debris. Also, the laundry room had a ceiling vent that was coated with a dark greyish substance and the entrance to the laundry room had a large space preventing the door from closing securely. In addition, two sinks were clogged and holding water in shared bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] located on the [NAME] wing. Findings include: During a tour of the facility on 3/4/2025 at 10:13 am revealed, an observation of the shower room on E3 hall had wall tiles missing or broken with sharp edges that were in hazardous condition. Observations on E4 hall revealed, there was brown substance on the privacy curtain and a build-up of brownish-black debris on the motorized wheelchair for R19, the laundry room ceiling vent was coated with a dark greyish substance, and the entrance had a large space preventing the door from closing; two sinks were clogged and holding water in shared bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] located on the [NAME] Wing. 1. Review of the facility's Performance Improvement Plan (PIP) on 3/5/2025 at 9:45 am revealed that tile replacement for shower rooms had not been identified. An observation and interview on 3/6/2025 at 9:55 am of the shower room on E3 with the Administrator revealed, shower walls had tiles missing or broken that were in hazardous condition. The Surveyor showed the Administrator the E3 hall shower room, and the Administrator confirmed that all four wall tiles needed to be repaired for the safety of residents. She revealed that staff did not identify the tiles needing replacement in the shower room on the Performance Improvement Plan (PIP), and the Administrator was going to add tile repairs to the PIP today, March 6, 2025. 39786 2. Record review of the Electronic Medical Record (EMR) revealed, R19 admitted to facility with primary diagnosis of malignant neoplasm of the lung. Review of R19's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 8 indicating mild-moderate cognitive impairment. MDS also reported no rejection of care, and a motorized wheelchair (w/c) was used for mobility. Review of the care plan for R19 revealed there was no care plan problem, goal, or approach that addressed cleaning the motorized wheelchair during the survey period from March 2, 2025, through March 6, 2025. However, the care plan was reviewed/revised on 3/6/2025 at 12:27 pm, after it was brought to the facility's attention of the Administrator and confirmed by the Housekeeping (HK) supervisor. Review of the revised care plan revealed the only approach (intervention) was to encourage him to contact his family when his wheelchair needs maintenance or cleaning. [sic] Observation on 3/2/2025 at 2:36 pm during initial tour and screening of residents revealed, the privacy curtain was stained with a brownish substance in R19's room and his motorized wheelchair had a build-up of brownish-black debris on it. Observation on 3/3/2025 at 9:05 am revealed R19 in bed, his motorized wheelchair was parked inside the room and observed to have a build-up of brownish-black debris on it and the privacy curtain was stained with a brownish substance. Observations on 3/3/2025 at 3:45 pm, on 3/4/2025 at 8:55 am, and on 3/6/2025 at 11:40 am of R19 sitting in his motorized wheelchair inside his room revealed the build-up of brownish-black debris on the motorized wheelchair and the privacy curtain was stained with a brownish substance. Observation on 3/4/2025 at 3:30 pm of R19 sitting in his motorized wheelchair in the common area of the facility revealed his motorized wheelchair had a build-up of brownish-black debris on it. Interview on 3/5/2025 at 12:15 pm with Housekeeping (HK) aide NN revealed she cleaned the resident rooms daily, but she was not sure who was supposed to clean the resident wheelchairs. Interview on 3/5/2025 at 12:25 pm with HK aide MM revealed HK cleaned resident's rooms every day. She was not sure who cleaned the wheelchairs. Interview on 3/5/2025 at 2:45 pm with Licensed Practical Nurse (LPN) OO revealed wheelchairs were cleaned per schedule and prn (as needed). Interview on 3/5/2025 at 2:50 pm with LPN PP confirmed wheelchairs were cleaned per schedule and prn. Interview on 3/5/2025 at 3:00 pm with Registered Nurse (RN) (RN HH) /Interim Director of Nursing (DON) revealed the HK supervisor was over HK staff and the floor techs, and wheelchairs were cleaned per schedule and prn by the floor techs. Interview on 3/6/2025 at 11:51 am with Certified Nursing Assistant (CNA) KK revealed the Floor Techs clean the wheelchairs. She was not sure about how often or if they followed a schedule, but she thought they had been cleaned recently. Observation and interview on 3/6/2025 at 11:52 am with the Housekeeping (HK) Supervisor revealed floor techs clean the resident wheelchairs. The manual w/c's are cleaned every two months, electric/motorized wheelchairs are only sanitized. She revealed motorized w/c's could not be washed down but HK staff should clean and sanitize the wheelchair by wiping them off with sanitizing wipes. She revealed they had two residents with a motorized wheelchair, R19 was one of the two and confirmed the motorized wheelchairs were cleaned per schedule. During an observation of R19 in his motorized w/c in the dining room, the HK supervisor confirmed R19's red [Brand name] motorized w/c was very dirty with a buildup of brownish black debris on it and needed to be cleaned. Observation and interview with the HK supervisor also confirmed the privacy curtain was stained with a brown substance in R19's room and it needed to be cleaned. 36377 3. Observation on 3/2/2025 at 2:10 pm revealed water holding in two sinks that were clogged in shared bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] located on the [NAME] Wing. Observation and Interview on 3/6/2025 at 1:33 pm of the facility laundry room with the Administrator and the Infection Control Preventionist (IP) revealed a ceiling vent coated with dark greyish substances. Below the vent were rack of resident clothes. The Administrator and the IP confirmed that the dark greyish substance could most likely be dust. Continued review of the laundry room entrance revealed a large space observed in between the two double entrance doors preventing the door from closing and allowing rodents, insects, and dust to enter the laundry room and cause contamination of resident clothes. Observation and Interview on 3/6/2025 at 2:10 pm with the Administrator confirmed water holding in two sinks that were clogged in shared bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] located on the [NAME] Wing.

Based on record reviews, staff interviews, and review of the facility's policy Advance Directive, the facility failed to provide residents and/or their representatives written information regarding the right to accept or refuse medical or surgical treatment for six out of 42 sampled residents (R) (R53, R48, R88, R94, R55, and R76). Findings include: Review of the facility's Advance Directive policy revised on [DATE] revealed, Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directive Checklist, which is in the Georgia Admission Packet, will be completed. Review of the facility's Admission Packet revealed it did not contain language that pertained to the facility's provision of written information about the resident/representative's right to accept or refuse medical or surgical treatment. 1. Review of medical records revealed, R53 was admitted to the facility on [DATE] with diagnoses that included but not limited to anoxic brain damage, not elsewhere classified and chronic respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R53's cognition was undetermined due to a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was unable to be completed. Review of medical record for R53 revealed, no signed acknowledgement or evidence the residents or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment, in the records. 2. Review of medical records revealed, R48 was admitted to the facility on [DATE] with diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease with (acute) exacerbation and unspecified lack of coordination. Review of the Quarterly MDS dated [DATE] revealed R48's BIMS score of 10, indicating moderate cognitive impairment. Review of medical record for R48 revealed no signed acknowledgement or evidence the residents or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment, in the records. 3. Review of medical records revealed, R88 was admitted to the facility on [DATE] with diagnoses that include but not limited to gastro-esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic kidney disease, unspecified, and type 2 diabetes mellitus with diabetic nephropathy. Review of the Quarterly MDS dated [DATE] revealed R88's BIM score of 14, indicating intact cognition. Review of medical record for R88 revealed no signed acknowledgement or evidence the resident or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment in the records. 49681 4. Review of medical records revealed, revealed that R94 was admitted on [DATE] with acute cystitis with hematuria, heart failure, and malignant neoplasm of prostate. Review of the Quarterly MDS dated [DATE] revealed R94's BIMS score of 13, indicating intact cognition. Review of R94's Admissions Packet revealed, the GA (Georgia) Advanced Directive for Healthcare form dated [DATE] that indicated Cardiopulmonary Resuscitation (CPR) status and Medical Interventions to include full treatment was selected and signed by the R94. Review of medical record for R94 revealed no signed acknowledgement or evidence the resident or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment in the records. Interview on [DATE] at 9:55 am with the Social Worker revealed the Admissions Coordinator is in charge of getting the advanced directive check list completed at admissions. She revealed the admissions coordinator is not currently working and that she is familiar with the admission packet and advance directives. The Social Worker revealed that she is not aware of any consent in the admission packet where a resident accepts or denies medical and surgical treatment. She printed the admission packet for R53, R48, R88, R94 and confirmed the paperwork did not include a consent for the resident to accept or deny medical or surgical treatment. Interview on [DATE] at 10:10 am with the Administrator revealed she was unfamiliar with the advance directive check list including the residents right to accept or refuse medical and surgical treatment. She revealed she would contact corporate. She contacted corporate and they advised the checklist is being revised and will be sent out to [Name] facilities when it clears legal. She confirmed that all residents in the facility have not been given materials on their rights to accept or refuse medical and surgical treatments. 39786 5. Review of medical records revealed R55 was admitted to the facility with primary admitting diagnoses of but not limited to type 2 diabetes mellitus with circulatory complications, type 2 diabetes with chronic kidney disease stage 3, congestive heart failure, hypertensive heart disease with heart failure, and epilepsy. Review of Physician orders revealed R55 had an order for DNR (Do Not Resuscitate) code status with start date [DATE]. Further review revealed a POLST (Physician Orders for Life-Sustaining Treatment) dated [DATE] signed by R55. Review of the Quarterly MDS assessment dated [DATE] revealed R55 was assessed with a BIMS score of 11 indicating mild cognitive impairment. Review of R55's Admission packet dated [DATE] revealed under the section titled, GA Advance Directive for Healthcare, option C was selected which documented, I have not executed an advance directive, and do not wish to discuss advanced directives further at this time. Further review revealed under the section titled, DNR, option C was selected which documented, I do not have a DNR Order or POLST in place and do not wish to discuss DNR further at this time. The admission packet was signed by R55's daughter, who was listed on file as the #2 primary contact. Review of medical record for R55 revealed no signed acknowledgement or evidence the resident or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment in the records. 6. Review of medical records revealed R76 had a primary diagnosis of chronic systolic (congestive) heart failure, partial intestinal obstruction, chronic atrial fibrillation, type 2 diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, essential (primary) hypertension, and hyperlipidemia. Review of Physician orders revealed R76 had an order for Full code status with a start date of [DATE]. Review of the Annual MDS assessment dated [DATE] did not assess a BIMS score for R76 related to short and long-term memory loss, and severely impaired decision-making skills. Review of the Admission packet with a completion date of [DATE] revealed R76 admitted to the facility on [DATE], and under the section titled, GA Advance Directive for Healthcare, option B was selected which documented, I have not executed an advance directive, but would like to obtain additional information and resources to complete an advance directive. Instructions and forms for completing a Georgia Healthcare Directive were provided to me. Further review revealed under the section titled, DNR, option B was selected which documented, I do not have a DNR Order or POLST in place but would like to obtain additional information and resources on how to have one executed on my behalf. Information regarding Georgia DNR Orders and/or POLST was provided to me. The admission packet had an electronic signature for R76. Review of medical record for R76 revealed no signed acknowledgement or evidence the resident or the resident's representative was provided written information about the right to accept or refuse medical or surgical treatment in the records. Interview on [DATE] at 3:17 pm with the Social Worker revealed information on Advanced Directives would be in the Admission packet. Review of the Admission packet for R55 and R76 confirmed there was no documentation that information on medical and/or surgical treatment options were provided or explained.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to assess four of 42 sampled residents (R) (R55, R37, R75, and R82) for the ability to self-administer medications (meds) prior to leaving meds at the bedside. The deficient practice had the potential to allow access to meds not prescribed by a physician for R55, R37, R75, and R82 and to other residents who may wander into the room. Findings include: Review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, revised 1/28/2020 under policy statement revealed, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. Further review revealed under, Procedure: 2. If the patient/resident or family member desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical and visual ability to carry out this responsibility . 5. Bedside Storage of Medications is permitted only when it does not present a risk to confused patients/residents who wander . Attending Physician enters an order, on the Electronic Health Record for bedside storage. 1. Review of the Electronic Medical Record (EMR) revealed R55 admitted to facility with diagnoses that included but not limited to type 2 diabetes with chronic kidney disease stage 3, type 2 diabetes mellitus with circulatory complications, congestive heart failure, hypertensive heart disease with heart failure, and epilepsy. Review of R55's Physician orders revealed there was no order for OTC (over the counter) Redness Relief Tetrahydrozoline eye drops and (Name) Lidocaine Pain Relief cream. Further review revealed there was no order for R55 to self-administer meds or have meds at bedside. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed R55 with a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment (a score of 8-12 indicates mild cognitive impairment). Review of the care plan revealed R55 was not care-planned for self-administration of meds. Review of a Self-Administration of Medication assessments for R55 dated 2/14/2025, 10/30/2024, 5/31/2024 and 2/6/2024 revealed the following: Where will self-administered medications be stored? Cart-Not Applicable - Resident won't be self-administering medications. Indicate care plan action taken. Continue current plan of care - Nurse to administer medications. Observation and Interview on 3/2/2025 at 4:43 pm revealed (Name) Tetrahydrozoline eye drops and (Name) Lidocaine Pain Relief cream in a small green basket at R55's bedside. R55 revealed she had arthritis or gout in her hand, it was very painful, and she put the cream on her left hand for pain relief. R55 also revealed her daughter brought the meds to her from home. Observation and interview on 3/2/2025 at 5:15 pm with Licensed Practical Nurse (LPN) LPN II/Nurse Manager confirmed the (Name) Tetrahydrozoline OTC eye drops, and the (Name) Lidocaine Pain Relief cream was at the bedside in a small green basket in R55's room. LPN II also confirmed R55 was not assessed for self-administration of meds, and they should not be there. R55 told the nurse her daughter brought them to her but did not remember how long ago it was. LPN II revealed she was not aware of the meds in the room. LPN II told R55 she was going to take the meds to the nurse station because she was not supposed to have them in her room. LPN II removed the eye drops and pain relief cream from R55's room. Interview on 3/6/2025 at 4:00 pm with the Administrator confirmed residents should not have meds inside their room without having been assessed for self-administration of meds. 36377 2. Record review of R37's EMR revealed diagnoses that included but not limited to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic respiratory failure with hypoxia, and morbid (severe) obesity. Review of R37's Quarterly MDS assessment dated [DATE] revealed, a BIMS score of 10 out of 15 which indicates moderate cognitive impairment. Review of R37's self-administration evaluation/assessment form titled Self-Administration assessment dated [DATE] revealed R37 was not assessed to self-administer medications. Observation on 3/2/20255 at 5:15 pm of R37's room with LPN II revealed the following medications within open view of anyone entering the room, a small bottle of (Name) acetaminophen (capsule) located on a dresser stand, a jar of (Name) medicated chest rub (3.53 oz-ounce) positioned on overhead table, and a tube of diclofenac sodium topical gel 1% (one percent) gel (prescription labeled with resident name) located on a small bedside dresser with open view of anyone entering the room. LPN II confirmed the unauthorized medications with the surveyors and removed the medications from R37's room. 3. Record review of R75's medical record revealed diagnoses that included but not limited to unspecified dementia, unspecified, hypertensive heart disease without heart failure, chronic kidney disease stage 4 (severe), and unspecified atrial fibrillation. Review of R75's Quarterly MDS assessment dated [DATE] revealed, a BIMS score of three out of 15 which indicates severe cognitive impairment. Review of R75's self-administration evaluation/assessment form titled Self-Administration assessment dated [DATE] revealed R75 was not assessed to self-administer medications. Observation of R75's room on 3/2/2025 at 5:15 pm with LPN II revealed the following medication, a small jar of lidocaine pain medication resting on the overhead table within view of anyone entering the resident room. R75 reported using the medicine to alleviate his tooth pain and gum pain. He reported using it at his free will without staff monitoring him. He could not explain who gave him the medications. LPN II confirmed the unauthorized medications with the surveyors and removed the medications from R75's room. 4.Record review of R82's EMR revealed diagnoses that included but not limited to chronic obstructive pulmonary disease, unspecified and acute respiratory failure with hypoxia. Review of R82's Quarterly MDS assessment dated [DATE] revealed, a BIMS score of 15 out of 15 which indicates little to no cognitive impairment. Review of R82's self-administration evaluation/assessment form titled Self-Administration assessment dated [DATE] revealed R82 was not assessed to self-administer medications. Observation of R75's room on 3/2/2025 at 5:15 pm with LPN II revealed the following medication fluticasone propionate and (Name) fluticasone, umeclidinium, and vilanterol-200 mcg(micrograms)/62.5mcg/25 mcg oral inhalation powder. LPN II confirmed the unauthorized medications with the surveyors and removed the medications from R75's room. During a later interview on 3/2/2025 at 5:19 pm, LPN II verified that resident R37, R75, and R82 had not been approved by the physician or assessed to self-administer medications. She reported being unaware of the above-mentioned residents having unauthorized medications at their bedside. LPN II reported that the protocol is that any resident who has an approval to self-administer medications need to be evaluated and care planned for self-administration of medication.

Based on staff interviews and record reviews, the facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for one of 42 residents (R) (R88). Specifically, the facility failed to complete an admission nutrition assessment for R88. Findings include: 1. Record review revealed, R88 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro-esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic kidney disease, unspecified, and type 2 diabetes mellitus with diabetic nephropathy. Review of R88's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognitive impairment. Review of R88's Physician Order Form (POF) included an order for regular puree diet, and an order for Glucerna dated 10/11/2024. Review of R88's care plan for nutrition dated 9/2/2024 identified a problem: Resident is at risk for GI (gastro-intestinal) complications/ altered nutrition. He receives a therapeutic diet. He is edentulous. Review of R88's medical records revealed, there was no admission nutrition assessment. Interview on 3/5/2025 at 1:35 pm with the prior Registered Dietician (RD), EE revealed she last worked for the facility in December 2024. She revealed she did not have any information for this surveyor regarding residents because she turned in her computer. She revealed that nine buildings for one RD was too much and things fell between the cracks. She revealed, when she was reassigned to the building in October 2024, she found that some admission assessments were not completed on newly admitted residents. She revealed she was able to see new admissions through the electronic health record via a report. She revealed she played catch up and got nutritional assessments done as timely as possible but some were overdue. Interview on 3/5/2025 at 2:28 pm with the Regional Nurse Consultant DD revealed that newly admitted residents should receive a nutritional assessment within the first 14 days of being admitted . She confirmed that the resident was admitted on [DATE] and the only nutritional assessment completed was on October 31, 2024. Interview on 3/5/2025 at 5:10 pm with the Administrator revealed that all newly admitted residents should have a nutritional assessment within 14 days of admission. She verified that the resident's assessment was not completed within 14 days. She said it was her expectation that the RD completed assessments for new admissions according to policy. A facility policy on nutrition assessments was requested but not provided. Interview on 3/5/2025 at 1:35 pm with the prior Registered Dietician (RD), EE revealed she last worked for the facility in December 2024. She revealed she did not have any information for this surveyor regarding residents because she turned in her computer. She revealed that nine buildings for one RD were too much and things fell between the cracks. She revealed, when she was reassigned to the building in October 2024, she found that some admission assessments were not completed on newly admitted residents. She revealed she was able to see new admissions through the electronic health record via a report. She revealed she played catch up and got nutritional assessments done as timely as possible but some were overdue. Interview on 3/5/2025 at 2:28 pm with the Regional Nurse Consultant DD revealed that newly admitted residents should receive a nutritional assessment within the first 14 days of being admitted . She confirmed that the resident was admitted on [DATE] and the only nutritional assessment completed was on October 31, 2024. Interview on 3/5/2025 at 5:10 pm with the Administrator revealed that all newly admitted residents should have a nutritional assessment within 14 days of admission. She verified that the resident's assessment was not completed within 14 days. She said it was her expectation that the RD completed assessments for new admissions according to policy. A facility policy on nutrition assessments was requested but not provided.

Based on observations, interviews and record review, the facility failed to promote, maintain, and protect residents' dignity for two of 42 sampled residents (R) (R11 and R67) who required assistance with feeding. Findings include: 1. Review of R11's Face Sheet revealed diagnoses that included but not limited to, Parkinson's disease without dyskinesia, without mention of fluctuations, moderate protein-calorie malnutrition, primary generalized (osteo)arthritis. Review of R11's Significant Change Minimum Data Set (MDS) dated [DATE] revealed, Section C-Cognition: Brief Interview of Mental Status (BIMS) score of two indicating severe cognitive impairment; Section GG-Functional Status: resident requires substantial maximal assistance with feeding. Review of R11's care plans dated 4/24/2020 revealed, R11 is at risk for GI (gastro-intestinal) complications/ altered nutrition. She has contributing Dx (diagnosis) of GERD (gastroesophageal reflux disease) and Malnutrition. She has poor appetite and refuses to allow staff to assist/ feed her, weight loss is anticipated. She receives a mechanically altered diet. She receives an antiulcer med routinely. Observation on 3/4/2025 at 8:45 am of R11 revealed, the Unit Manager FF was standing beside the bed feeding R11. Observation on 3/5/2025 at 9:30 am of R11 revealed, Unit Manager FF, was standing and feeding R11. 2. Review of R67's Face Sheet revealed diagnoses that included but not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, dementia, unspecified protein-calorie malnutrition, Review of R67's Annual MDS dated [DATE] revealed, Section C-Cognition: BIMS score of 00 indicating severe cognitive impairment; Section GG-Functional Status: resident is dependent for eating: Section K-Swallowing/Nutritional status - Resident is on Mechanically altered diet/ Therapeutic diet Review of R67's care plans dated 1/5/2023 revealed, R67 is at risk for GI complications/ altered nutrition. She has contributing Dx of CVA (cerebrovascular accident), dementia and malnutrition. She receives a pureed diet. She has poor dental status and poor appetite. Observation on 3/5/2025 at 9:30 am of R67 revealed, Certified Nursing Assistant (CNA) CNA GG was standing and feeding R67 breakfast. Interview on 3/5/2025 at 9:40 am with CNA GG revealed that when feeding residents, she should be sitting at eye level of the resident. It was revealed that she has had training on how to properly feed residents that need assistance with eating Interview on 3/5/2025 at 10:06 am with the Director of Nursing (DON) HH confirmed that when feeding residents, staff should be sitting at eye level of the resident, and the head of the bed should be elevated. He revealed that he expects staff to follow all policies and procedures when feeding residents. Interview on 3/5/2025 at 10:15 am with Unit Manager FF, revealed that when feeding residents, she makes sure to wash their hands, she raises the bed to her level so that she can feed them, she revealed that she stands while feeding R11 because there is no extra chair in the room. She revealed that she does not know if you are supposed to sit or stand when feeding residents. It was revealed that she was not sure if there have been any in-services on the procedures for feeding residents. Interview on 3/6/2025 at 10:55 am with the Administrator revealed when a staff assists a resident with feeding, they should sit with them, ensure they have the appropriate utensils, converse with them, and ask resident what they would like to eat first. She revealed that sitting with the resident is not required but it's best practice.

Based on record review, and Staff interviews, the facility failed to ensure that Activity of Daily Living (ADL) records were accurately documented for one of 14 Residents (R) (R2). Findings include: Record review for R2 revealed resident was admitted to the facility with diagnoses not all inclusive of hemiplegia and hemiparesis, flaccid hemiplegia affecting left nondominant side, and absence of right leg above knee. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R2 was cognitively intact. Review of R2's ADL bathing log March 2023 - September, revealed no documented showers. Review of R2's complete medical record revealed no documented refusal of showers. Interview on 10/5/2023 at 11:20 a.m., Certified Nursing Assistant (CNA) II stated that she was responsible for taking care of R2. CNA II stated, She likes showers and I give her those. When asked the last time she showered R2, CNA II stated, Oh, it has been a while. Maybe three to four weeks ago. I document the showers in the tablet. When asked to show her documentation, CNA II stated, I don't document it as a shower, I document it as a bed bath. CNA II was unable to state why she documented showers as bed bath. When asked how she documented showers for other residents, CNA II stated that she documented them as showers, not bed baths. Interview on 10/5/2023 at 12:00 p.m., the Director of Health Services (DHS) stated she was aware of the R2 having a shower as her preference. The DHS confirmed the ADL documentation revealed R2 had not received a shower from March 2023 - September 2023. The DHS stated, The staff said that she doesn't want to get out of bed sometimes. The DHS stated if a resident refuses care, the refusal should be documented in the resident's record.

Based on record review, and staff interviews, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure the resident assessment accurately reflected a resident's status for one of 14 residents (R) (R1). Specifically, the facility failed to ensure that R1 Minimum Data Set (MDS) was accurately coded to reflect residents documented wandering behavior and risk for elopement. Findings include: Review of the facility policy titled, MDS Assessment Accuracy with revised date of 12/6/2022 revealed under Policy Statement: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical statis of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. The Interdisciplinary Team (IDT) is responsible to obtain the input that is needed for clinical decision making that is consistent with relevant clinical standards of practice. R1 was admitted to the facility with the following diagnoses: chronic kidney disease and insomnia. Review of R1's Elopement Risk Observation dated 1/25/2023, revealed an elopement score of 14, indicating high risk for elopement. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed this MDS did not capture R1's wandering and exit seeking behavior. Interview 10/5/2023 at 9:27 a.m., MDS Coordinator (MDSC) GG stated wandering is under the mood and behavior section of the MDS. MDSC GG stated the Social Services Director (SSD) was responsible for that section. Interview 10/5/2023 at 9:44 a.m., MDSC HH stated, If someone wanders that is communicated through nursing and nursing assistants. If a resident has that behavior after admission, we are clued in on it. If they begin to exhibit the behavior, we transfer them to the memory support unit. If someone elopes, we know through the code system. If they have wandered during the lookback period, it should be coded. With the ARD (assessment reference date) being 1/31/2023 and there's a 7-day lookback period and that should have been captured on the MDS. During an interview on 10/5/2023 at 10:00 a.m., the SSD stated, Yes, I am responsible for the mood and behavior section of the MDS. I would have coded it as such if I was aware.

Based on record review, resident interview, Family interview, staff interviews, and review of facility policy titled, Grievances: Healthcare Centers, the facility failed to ensure prompt efforts were made to resolve grievances related to shower preferences and personal property, for one of 14 residents (R) (R2). Findings include: Review of facility policy titled Grievances: Healthcare Centers, revised 11/21/2022, under Procedures: 3. Once the referral is made to the responsible discipline, the responsible discipline will make prompt efforts to resolve the grievance, in addition to taking immediate action to prevent further potential violation of and patients' rights while the alleged violation is being investigated. 4. The Administrator or designee will be responsible for follow-up with the patient, authorized individual or other representative to determine the grievance has been resolved and to ensure the grievance process is understood. 5. The Grievance/Complaint should be resolved within three business days. Record review for R2 revealed resident was admitted to the facility with the following, but not limited to, diagnoses of Hemiplegia and hemiparesis, diabetes, moderate vascular dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R2 was cognitively intact. Review of Grievance Complaint Form dated 2/16/2023 revealed, [Family of R2] came into the SSD (Social Services Director) office and she had some concerns. She stated the following: 'She had a wheelchair, and we cannot find it. The one that is in her room is not hers.' and 'I would like her to be showered more.' Interview on 10/2/2023 at 3:15 p.m., revealed R2 stated she had not been showered by the facility staff any this year. R2 stated her last shower was in June, and it was given by Family of R2. R2 stated, I receive several bed baths during the week but no showers. I don't want a shower every day. Just one or two times a week. Interview on 10/2/2023 at 3:18 p.m., with Family of R2 stated she has told the facility several times about R2's preference to shower. Family of R2 confirmed she showered R2 in June but has not been able to shower R2 since that time. Family of R2 stated she had spoken about the shower preference at care plan meetings and had written grievances about the issue. Interview on 10/4/2023 at 11:00 a.m., the SSD stated she was responsible for following up on grievances and giving the grievances to the correct department, When I got this grievance, I didn't address the wheelchair. With the shower, I passed that along to the nursing department. Interview on 10/5/2023 at 11:20 a.m., Certified Nursing Assistant (CNA) II stated that she was responsible for taking care of R2. CNA II stated, She likes showers and I give her those. When asked the last time she showered R2, CNA II stated, Oh, it has been a while. Maybe three to four weeks ago. Interview on 10/5/2023 at 11:28 a.m., CNA JJ stated she was responsible for taking care of R2. CNA JJ stated, Sometimes she requests showers. It has been more than three months since I showered her. CNA JJ was unable to state when she had last showered R2. Interview on 10/5/2023 at 12:00 p.m., the Director of Health Services (DHS) confirmed her knowledge of the 2/16/2023 grievance. The DHS stated that she was aware that R2 preferred showers but could not state how she had passed this information on to the nursing staff.

Based on observations, staff interviews, and review of facility policy titled, Infection Control-Housekeeping Services, the facility failed to maintain a clean, sanitary environment related to a heavy build-up of dust on the vent covers in nine (9) of 21 adjoining resident bathrooms in rooms (Rms) 3/5, 4/6, 8/10, and 7/9 on West (W) Hall, and in Rms 12, 14/16, 17/19, 18/20, and 21/22 on the Memory Unit. The deficient practice had the potential to affect the air quality for all the residents residing in resident care areas. Findings include: Review of policy titled, Infection Control-Housekeeping Services, revised dated 1/15/2016 revealed the facility will ensure housekeeping services will be performed on a routine and consistent basis to ensure sanitary environment. A deep cleaning will be performed for each resident room monthly and as needed. Cleaning methods and machines that re-suspend dust from surfaces will be avoided, especially in resident care areas. Observations during initial tour and screening of residents on 12/20/2022 starting at 10:00 a.m., and observations on 12/21/2022 starting at 8:30 a.m., revealed a heavy build-up of dust on the ceiling vent cover in bathrooms 3/5W, 4/6W, 8/10W, 7/9W on West Hall, and in rooms 12, 14/16, 17/19, 18/20, and room [ROOM NUMBER]/22 on the Memory Unit. Interview on 12/21/2022 at 8:30 a.m. with Housekeeping (HK) Aide FF revealed her duties were to clean surfaces starting up high, that included the lights, windowsills, and dusting with a long handle brush. We work our way down, wipe down surfaces with a Peroxide disinfectant spray, empty trash, sweep, mop, and do the bathrooms last. Interview further revealed one thing HK didn't do was clean the vents, the floor tech is responsible for cleaning the vents. The floor tech takes them outside and clean them when needed. Interview on 12/21/2022 at 10:25 a.m. with Floor Tech HH revealed his duties were to sweep, mop, buff, strip, and wax floors. He revealed it was the maintenance department's primary responsibility to clean the air/intake vents but sometimes they ask housekeeping (HK) to clean them, and HK do have a brush they dust with. During a walk-through on 12/22/2022 with the Assistant Administrator, confirmed the vent covers were dirty with a heavy build-up of dust in bathrooms 3/5W, 4/6W, 8/10W, 7/9W on West Hall, and in rooms 12, 14/16, 17/19, 18/20, 21/22 on the Memory Unit. Interview on 12/22/2022 at 12:16 p.m. the Administrative Assistant revealed the floor tech is responsible for cleaning the vents and they follow a routine cleaning schedule. He revealed it was because they had done some work on West Hall that caused an extra build-up of dust, they had staff out sick and were short staffed. Interview further confirmed the dusty vents were unacceptable, and his expectation was that the vents should be clean.

Based on observations, staff interviews, and review of the facility's policy titled, Receipt and Storage of Food & Supplies and the facility policy titled, Leftovers. The facility failed to ensure that foods were properly labeled and dated in the dried foods pantry and to failed to discard expired foods in the walk-in cooler in the main kitchen. The deficient practice had the potential to affect 127 of 138 residents receiving an oral diet. Findings include: Review of the facility policy titled, Receipt and Storage of food and Supplies dated [DATE] revealed that in procedure section item number seven; The first in, first out (FIFO) method must be used to ensure proper rotation of all food items to prevent spoilage. Further facility policy review titled Leftovers dated [DATE] revealed under procedure section number five any food that is leftover may be used as follows: leftovers must be used within 72 hours (3 days). Kitchen Observation on [DATE] at 5:39 a.m. revealed during the tour of the dried food storage pantry all foods were labeled with a receive date and no expiration date. Interview with Dietary Manager (DM) at time of observation revealed that staff usually uses up the product that is opened within thirty days. Further interview revealed that food is discarded after the thirty days from the date that the food item is opened. Further observation of the pantry revealed a one-quart size zip lock bag of dried cereal was not labeled or dated which was confirmed by the DM. Observation of the walk-in cooler on [DATE] at 6:00 a.m. revealed a medium size tin pan of cut up fruit unlabeled with no open date observed, a small tin pan of gravy dated for [DATE] with no discard date. Further observation revealed a 180 oz container of Pace Enchilada Sauce with an expiration date of (MONTH) 20, 2019 which was confirmed by DM to be expired. Interview with DM on [DATE] at 6:15 a.m. in reference to when left over food items are to be discarded revealed that food items are to be discarded three days after the date food item was stored in the cooler and that all dietary staff were aware of this facility policy. Further interview with DM confirmed that the tin pan of gravy dated [DATE] was stored past the discard date in the walk-in cooler. Interview with Administrator on [DATE] at 9:00 a.m. in reference to expectations of discarding expired foods revealed that expired foods should be discarded immediately.

Based on observation, staff interview and record review, it was determined that the facility failed to provide a restorative nursing program (RNP) or functional maintenance program (FMP) to maintain the ability of one resident ("F") to transfer and ambulate, of 10 residents reviewed with impaired range of motion or contractures, from a total sample of 25 residents. This resulted in actual harm of functional decline for resident "F". Findings include: Resident "F" had [DIAGNOSES REDACTED]. On the 10/1/10 initial care plan, licensed staff identified his/her self care deficit and included an intervention for passive range of motion exercises as tolerated. The resident was admitted to the facility on [DATE] and had received skilled physical therapy until 10/27/10. On the 9/24/10 evaluation, the physical therapist (PT) documented that the resident's prior level of function, prior to hospitalization , had been walking and transferring independently. The PT documented that the resident's spouse's goal was for the resident to be able to walk again so that he/she could be discharged back to the home environment. On the 9/24/10 evaluation, the PT documented that the resident's lower extremity range of motion was limited because of rigidity and, adductor (bringing towards the body) and extensor (bringing away from the body) muscle tone. On the 10/21/10 progress and the 10/27/10 discharge note, the PT documented that the resident's rigidity had considerably decreased which allowed for exercises to be done by the resident. The PT documented on those notes that the resident was able to walk 20 to 25 feet with a rolling walker, requiring moderate assistance (50% caregiver assistance) of one person to minimal assistance (25% caregiver assistance) of two people, and required moderate assistance of two persons for transfers. On 10/27/10, the PT documented that the resident had reached his/her maximum level of function and was to be discharged from skilled PT on 10/27/10. However, there was no evidence that a plan had been developed and implemented to assist resident "F" to maintain his/her highest practicable functioning with ambulation and transfers. There was no evidence of any staff education about the resident's ability to transfer and ambulate prior to his/her discharge from PT services. A review of the nurse's notes revealed that, on 2/6/11, licensed nursing staff had requested a therapy evaluation of the resident's ambulation, mobility, range of motion and contractures. Licensed nursing staff documented that the resident had stated that he/she would like some therapy. However, a review of the clinical record revealed that, as of 3/8/11, the resident had not been seen by the therapy staff for evaluation. On 3/8/11 at 1:55 p.m., the speech therapist reviewed all referrals made to the therapy department from nursing staff and confirmed that the resident had not been screened by therapy staff. On 3/7/11 at 2:35 p.m., CNA staff had transferred resident "F" from his/her wheelchair to the bed using the Hoyer lift. During an interview on 3/9/11 at 11:30 a.m., licensed nurse "BB", certified nursing assistant (CNA) "AA" and licensed nurse "JJ" stated that the resident was not able to stand or bear weight and, they were not aware of the resident's prior ability to ambulate. CNA "AA" stated that the resident was not able to pivot or bear weight with transfers. Licensed nurse "BB" stated that the resident changed from being able to transfer with the assistance of two persons to being dependent on the use of a Hoyer lift approximately two weeks ago. On 3/9/11 at 9:00 a.m., the restorative CNA stated that the resident was not seen by anyone from the restorative nursing program. On 3/9/11 at 8:30 a.m., CNA "AA" stated that staff did not provide passive range of motion exercises for the resident's lower extremities because of tightness. On 3/9/11 at 9:30 a.m., CNA "AA" attempted passive range of motion exercises on the resident's knees. However, she was only able to flex the resident's knees approximately 30 degrees.

Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to appropriately review and revise care plans to ensure the ongoing development of effective interventions and approaches to provide adequate supervision related to repeated falls for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck their heads a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to reassess and reevaluate these residents and their Plans of Care appropriately to develop interventions and approaches to minimize falls had resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurrence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of the appropriate interventions. However, during an interview conducted with Nurse "EE" on 09/02/2010 at 9:30 a.m., this nurse acknowledged that the facility did not reevaluate residents for falls. During an interview conducted with Nurse "EE" on 09/02/2010 at 11:10 a.m., this nurse stated that high risk fall assessments were not being completed periodically on residents, and that resident Care Plans were not being revised to reflect new interventions to prevent falls. During an additional interview with Nurse "EE" conducted on 09/23/2010 at 1:00 p.m., this nurse stated that the facility did initial assessments on residents at the time of admission to determine the fall risk, but reiterated that the facility did not reevaluate residents for falls. During an interview conducted with the Director of Nursing on 08/30/2010 at 3:30 p.m., the Director of Nursing acknowledged that residents had not been adequately assessed for falls. 1. Cross refer to F323, example 1. Record review for Resident #2 revealed an MDS assessment of 01/11/2010 documented that the resident's date of admission was 12/30/2009, and documented [DIAGNOSES REDACTED]. The Resident Care Plan for Resident #2 reference a 01/11/2010 entry which identified falls as a problem both prior to admission and since admission secondary to unsteady gait/balance, the resident's behavior of transferring unassisted at times, and [MEDICAL CONDITION]. Approaches to address this resident's fall risk included the use of a personal protection alarm at all times and to monitor and report any attempts to transfer/ambulate unassisted. Record review revealed Incident Reports of 03/30/2010 at 12:45 p.m., 04/03/2010 at 4:00 p.m., 04/07/2010 at 5:40 a.m., 04/30/2010 at 7:00 p.m., 06/05/2010 at 7:00 p.m., 06/22/2010 at 2:00 p.m., 06/25/2010 at 11:50 a.m., and 08/13/2010 at 4:30 p.m. which documented that Resident #2 had experienced falls. Additionally, a 04/28/2010 Incident Report timed at 5:00 a.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall while getting out of bed, and was assessed to have a small amount of bleeding from the left nostril was noted, and a 1 inch in diameter raised area was noted on the resident's left frontal hairline. The resident's left cheek and eye were red and swollen, with an eyeball hemorrhage noted in the outer aspect of the eye, and the right knee was red with an abrasion. Also, a Nurse's Note dated 07/16/2010 at 7:45 a.m. documented that Resident #2 had an unwitnessed fall on 07/15/2010 at 7:50 p.m., and that the resident stated she had bumped her head. Based on the above, the facility had identified Resident # 2 to be at risk for falls, with a 01/11/2010 Resident Care Plan entry identifying this risk and Approaches to address the risk, which included the use of a personal protection alarm at all times. However, the resident experienced ten (10) subsequent falls between 03/30/2010 and 08/13/2010 from the bed, the wheelchair, or while ambulating, with the 04/28/2010 fall resulting in the resident striking the head, causing a raised area on the hairline, left cheek and eye swelling, and an eye ball hemorrhage. Review of the Resident Care Plan revealed an updated entry of 03/16/2010 indicating the resident was on the wheelchair positioning program. However, the specific falls of 04/30/2010 and 06/25/2010 occurred while the resident was in the wheelchair, after the initiation of this 03/16/2010 intervention. But, further record review, to include review of the Resident Care Plan, revealed no evidence to indicate that the facility had reassessed and revaluated the resident to identify additional interventions and approaches to address the resident's continued falls from the wheelchair, or to identify additional interventions to address the resident's continued falls from the bed and while ambulating. Based on the above, the facility failed to appropriately reassess and reevaluate Resident #2, who received [MEDICATION NAME] anticoagulant drug therapy, to develop effective interventions to address the resident's continued falls, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident from continuing to sustain falls, including one fall which resulted in injury. 2. Cross refer to F323, example 2. Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment of 09/09/2009 which documented that the resident had been admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The resident's Resident Care Plan contained an entry, originally dated 09/09/2009, which identified that the resident was at risk for falls related to a history of falls and a cognitive deficit. This Care Plan identified multiple Approaches to address this resident's risk for falls, including to provide the limited assistance of one person with ambulation and transfers, to monitor the resident's gait and to provide more assistance as needed. Care Plan Approaches also included the use of a bed alarm to alert staff of any attempts of the resident to rise from bed without assistance, although a 02/05/2010, 9:30 a.m. Nurse's Notes Quarterly Review indicated that the resident had utilized a bed alarm in the past, but that it had been discontinued at that time. Record review revealed Nurse's Notes and/or Incident reports of 03/09/2010 at 1:50 a.m., 03/30/2010 at 2:30 p.m., 04/07/2010 at 6:15 p.m., 05/08/2010 at 3:30 a.m., 05/25/2010 at 4:25 p.m., 06/14/2010 at 2:10 p.m., 06/29/2010 at 9:00 p.m., and 07/01/2010 at 9:30 a.m. which documented that Resident #1 had experienced falls. Additionally, Resident #1 experienced the following falls during which she struck her head resulting in redness or injury: A Nurse's Note of 04/14/2010 at 8:30 p.m. documented that the resident was sitting in the common area in a recliner, fallen to the floor, and was assessed to have a reddened area on the left forehead. A Nurse's Note of 04/19/2010 at 6:30 p.m. documented that the resident was on the floor in the bathroom and was noted to have a reddened area on the posterior scalp. A Nurse's Note of 05/21/2010 at 3:30 p.m. documented that staff had found the resident on the floor in the bathroom, having bumped her head on the floor causing a hematoma. A Nurse's Note of 06/14/2010 at 2:10 p.m. documented that the resident was found on the floor between the doorway of another resident's room in the hallway, having slight redness to the head upon assessment. Record review revealed that the facility, as one specific intervention, had initiated via a physician's orders [REDACTED]. However, further record review revealed no evidence to indicate that, after having initially assessed the resident to be at risk for falls and devising Approaches on the 09/09/2009 Resident Care Plan to address this risk, the facility had reevaluated the resident to develop additional interventions related to the eleven (11) subsequent falls the resident sustained [REDACTED]. And, specifically during the falls of 03/30/2010, 04/14/2010, 04/19/2010, 05/21/2010, and 06/14/2010, the resident hit her head, requiring the initiation of neurological checks, with the fall of 05/21/2010 also resulting in a hematoma. Based on the above, the facility failed to adequately reassess and reevaluate Resident #1, who received aspirin anticoagulant drug therapy, to develop effective approaches and interventions to address the resident's continued falls, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, including falls resulting in injury. 3. Cross refer to F323, example 3. Record review for Resident #7 revealed an MDS of 03/26/2010 which documented a date of entry to the facility of 03/16/2010, and which documented that the resident had [DIAGNOSES REDACTED]. The Resident Care Plan for Resident #7 identified a problem, with an original date of 03/25/2010, of the resident being at risk for falls related to a history of falls, poor cognition, muscle weakness, and an unsteady gait. This Care Plan included, as Approaches to address the resident's risk for falls, for staff to assist the resident with ambulation as needed and tolerated, and for a bed alarm to be used while in bed. Record review revealed Incident Reports dated 03/26/2010 at 6:00 p.m., 03/27/2010 at 4:00 p.m., 03/30/2010 at 10:30 a.m., 03/30/2010 at 4:45 p.m., 04/10/2010 at 9:00 a.m., 04/12/2010 at 08:30 a.m., 04/18/2010 at 4:00 a.m., 06/04/2010 at 2:10 p.m., 07/11/2010 at 7:00 a.m., 07/13/2010 at 1:00 p.m., 07/26/2010 at 5:15 a.m., and 08/22/2010 at 10:50 a.m. which documented that Resident #7 had experienced falls. Additionally, Resident #7 had experienced the following falls resulting in the resident striking her head and/or sustaining injury: An Incident Report dated 04/07/2010 at 2:00 p.m. documented that the resident had fallen while ambulating ad lib in the common area and had sustained a five-and-one-half (5 1/2) cm. by four (4) cm. hematoma to the posterior head. An Incident Report dated 05/16/2010 at 2:15 p.m. documented that the resident had experienced an unwitnessed fall in the resident's room, and a red/purple area on the lower back of the resident's right hip was noted. An Incident Report of 05/31/2010 at 7:20 a.m. documented that the resident had experienced an unwitnessed fall and had sustained a skin tear to the right elbow. An Incident Report of 06/18/2010 at 7:20 a.m. documented that the resident had experienced an unwitnessed fall, was observed with her head propped against the bed stand, and was noted with a hematoma on top of the head. An Incident Report of 07/21/2010 at 7:45 p.m. documented that the resident fell between the chair and couch, and sustained a one (1) inch laceration to the right brow. The facility had identified Resident #7, who received aspirin anticoagulant drug therapy, to be at risk for falls, with a 03/25/2010 Resident Care Plan entry identifying this risk and Approaches to address the risk. However, the resident experienced fourteen (14) subsequent falls between 03/26/2010 and 08/22/2010 from the recliner or while ambulating, with the resident hitting her head during the specific falls of 04/07/2010, 04/15/2010, and 07/21/2010, sustaining a hematoma to the head during the fall of 04/07/2010 and a laceration to the head during the fall of 07/21/2010. There was, however, no evidence to indicate that the facility reevaluated the resident for continued falls from the recliner and while ambulating after the initial assessment of 03/25/2010. Additionally, the resident experienced a fall from the bed on 04/18/2010, resulting in the addition of a low rise bed on 04/27/2010 and the discontinuation of the use of the bed alarm on 05/07/2010, as documented in entries to the Resident Care Plan. The resident then experienced another fall from the bed on 05/16/2010, but there was no evidence to indicate that the facility reassessed and reevaluated the resident after this fall from the bed to identify interventions to prevent further falls, and the resident thus sustained two (2) subsequent falls from the bed, on 05/31/2010 and 06/18/2010, with the resident hitting her head and sustaining a hematoma to the head during the fall of 06/18/2010. Based on the above, the facility failed to reassess and reevaluate Resident #7, who received aspirin anticoagulant drug therapy, to develop effective interventions to address the resident's continued falls. The facility thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, including falls resulting in injury. 4. Cross refer to F323, example 4. Record review for Resident #8 revealed an Admission MDS of 12/30/2008 which documented the resident had been admitted to the facility on [DATE]. The Resident Care Plan for Resident #8 identified, as an entry originally dated 09/28/2009, that the resident was at risk for falls related to cognitive deficit and an unsteady gait, with Approaches which included the use of a wheelchair for locomotion, responding promptly, and keeping the call light within easy reach, even though this Care Plan also noted that the resident's cognition might be such that she could not use the call light. This Care Plan referenced additional Approaches, also dating from 09/28/2009, specifying the application of a bed alarm to the bed and the application of a patient protector alarm while out of bed, but a notation on the Care Plan documented that these Approaches had been discontinued on 02/15/2010. The Care Plan for falls also referenced an entry dated 05/31/2010 which specified the use of a left half-rail for bed mobility. Record review revealed Incident Reports dated 07/17/2010 at 10:05 p.m., 07/22/2010 at 5:35 p.m., 08/04/2010 at 2:45 a.m., and 08/08/2010 at 1:30 a.m. which documented that Resident #8 had sustained falls. The facility had identified Resident #8 to be at risk for falls, with a 09/28/2009 Resident Care Plan entry identifying this risk and Approaches to address the risk, two of which were the use of bed and patient protector alarms which were then discontinued on 02/15/2010. The facility then implemented, per the Care Plan, the use of a half-rail in the bed as an additional intervention to address falls on 05/31/2010. However, the resident then experienced four (4) subsequent falls between 07/17/2010 and 08/08/2010, with a fall of 07/22/2010 being from the wheelchair and a fall of 08/08/2010 being from bed, but there was no evidence to indicate that the facility had reevaluated the resident for these continued falls to develop interventions and approaches to prevent further falls. Based on the above, the facility failed to appropriately develop effective interventions to address Resident #8's continued falls, including falls from the bed and wheelchair, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls. It was determined that the immediate jeopardy was removed as of September 23, 2010, at which time the facility had completed the following actions: - On 08/31/2010, policy revisions were made for Head Injury, and licensed staff members were inserviced by the Director of Nursing. - On 09/08/2010, policy revisions were made for Fall Risk Precautions, and were reviewed by the Director of Nursing presented to staff members via inservice training. - On 09/13/2010, a policy was put into place requiring that all new incidents be reviewed in the morning clinical staff meeting by the Interdisciplinary Team to ensure that interventions were put into place, and that Care Plans and ADL's were updated with new interventions. This process was inserviced and monitored by the United Clinical Consultant during the first week of implementation. The Director of Nursing was then be responsible for the conducting of the morning clinical meeting as of 09/22/10. - On 09/14/2010, the incident Occurrence Reduction Program was implemented. Then, on 09/21/2010, inservice was provided to licensed nursing staff regarding the Occurrence Reduction program. - On 09/14/2010, a 100 % review of all incidents that had occurred in the facility for the past 60 days was completed by United Clinical Services Consultants to assess interventions and follow-up, and to determine if residents met the criteria for the Occurrence Reduction program. Four (4) residents met the criteria to be placed on the occurrence reduction program. - On 09/17/2010, remaining residents had been assessed and determined to have appropriate interventions and Care Plans, and ADL Records were updated to reflect interventions. - On 09/22/2010, a schedule was implemented, per the Occurrence Reduction program, to ensure that each resident has a fall risk assessment each, and licensed nursing staff were inserviced on completing occurrence reports, implementing interventions, updating Care Plans, and ADL records. - The facility will review all findings of assessments and the progress of the newly implemented policies and procedures in the next Quality Assurance Meeting scheduled on Friday, September 24, 2010. - Newly employed nurses will be educated, upon hire, regarding the Occurrence Reduction program, falls assessments, completing incident reports, updating care plans, ADL records and assessment for residents change in condition. Based on the corrective plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on September 23, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted inservice training to many licensed nursing staff members regarding the Occurrence Reduction Program as of 09/22/2010, but six (6) nursing staff received this inservice training on 09/23/2010, the last day of this complaint survey. Monitoring will be required to assure that this training is ongoing and has resolved the identified problems with both existing and new staff. Additionally, the facility is to have weekly Occurrence Reduction Program meetings to discuss residents determined to meet criteria for inclusion into the Program, but the first weekly meeting was not held until 09/23/2010, the last day of this survey. Also, the progress of the newly implemented policies and procedures is to be monitored through the facility's Quality Assurance program, but the next Quality Assurance Meeting was not scheduled to occur until Friday, 09/24/2010, the day after the completion of this complaint survey. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "E" level.

Based on resident medical record review, facility Incident Report review, review of the facility's Fall Occurrence Reduction Program Policy, and staff interview, it was determined that the facility failed to provide adequate supervision, related to repeated resident falls, for four (4) residents (#1, #2, #7, and #8), who had been assessed as being at risk for falls, on a total survey sample of twenty (20) residents. These four (4) residents experienced a total of forty-three (43) falls during the period extending from 03/09/2010 through 08/22/2010, sustaining injuries including hematomas to the head, bleeding from the nostril, eye and cheek swelling, an eyeball hemorrhage, elbow lacerations, and bruising to the hip. Additionally, Residents #1, #2, and #7, all of whom received anticoagulant drug therapy, struck the head a total of five (5) times, two (2) times, and three (3) times, respectively, during these falls. The failure of the facility to appropriately and adequately supervise these residents and implement effective interventions to minimize falls resulted in a situation in which the non-compliance was likely to cause serious injury, harm, impairment, or death for these four (4) residents, and for all residents at risk for falls. It was therefore determined that an immediate and serious threat to resident health and safety existed on April 28, 2010, and was removed on September 23, 2010, at which time the facility implemented a plan to remove the immediate jeopardy. Findings include: Review of the facility's Fall Occurence Reduction Program Policy revealed the policy indicated that all residents would be assessed for their risk for falls upon admission, and then quarterly and upon any decline or improvement in status, residents would be reassessed for their fall risk, with the implementation of the appropriate interventions. However, during an interview conducted with Nurse "EE" on 09/02/2010 at 9:30 a.m., this nurse acknowledged that the facility did not reevaluate residents for falls. During an additional interview with Nurse "EE" conducted on 09/23/2010 at 1:00 p.m., this nurse stated that the facility did initial assessments on residents at the time of admission to determine the fall risk, but reitterated that the facility did not reevaluate residents for falls. During an interview conducted with the Director of Nursing on 08/30/2010 at 3:30 p.m., the Director of Nursing acknowledged that residents had not been adequately assessed for falls. 1. Record review for Resident #2 revealed an MDS assessment of 01/11/2010 documented that the resident's date of admission was 12/30/2009, and documented [DIAGNOSES REDACTED]. This MDS also indicated that the resident had short-term and long-term memory problems, had moderately impaired cognitive skills for daily decision making, required the limited physical assistance of one person with walking in the room and in the corridor, required the extensive physical assistance of two-plus persons for transfer, had an unsteady gait, and had fallen in the past 30 days. An MDS assessment of 03/29/2010 indicated that the resident continued to have short-term and long-term memory problems, had moderately impaired cognitive skills for daily decision making, and continued to require the limited physical assistance of one person with walking in the room and in the corridor, required the extensive physical assistance of two-plus persons for transfer, and had an unsteady gait. The Resident Care Plan for Resident #2 reference a 01/11/2010 entry which identified falls as a problem both prior to admission and since admission secondary to unsteady gait/balance, the resident's behavior of transfering unassisted at times, and vertigo. Approaches to address this resident's fall risk included the use of a personal protection alarm at all times and to monitor and report any attempts to transfer/ambulate unassisted. During interview with Nurse "EE" conducted on 09/23/2010 at 1:20 p.m., Nurse "EE" acknowledged that the Resident Care Plan specified for the resident to have a personal protection alarm applied at all times. Review of the August 2010 physician's orders [REDACTED].) daily. An Incident Report of 04/30/2010 documented that at that time, the resident was receiving Coumadin, 7.5 mgs. on Monday, Wednesday, and Friday, and Coumadin 5 mgs. on Tuesday, Thursday, Saturday and Sunday. A 03/30/2010 Incident Report timed at 12:45 p.m. documented that Resident #2 was found on the floor, having experienced an unwitnessed fall with no staff present at the time of the fall. This Report documented that the resident stated she was trying to go to the bathroom. The Report also documented that the resident had gotten out of bed unassisted, and that no personal protection alarm was in use at the time of the fall. A 04/03/2010 Incident Report timed at 4:00 p.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall with no staff present at the time of the fall. This Report documented that the resident had slipped off the bed while attempting to get up without assistance, and that no personal protection alarm was present at the time of the fall. A 04/07/2010 Incident Report timed at 5:40 a.m. documented that Resident #2 had been found on the floor, having experience an unwitnessed fall with no staff present at the time. This Report documented that no personal protection alarm was present at the time of the fall. A 04/28/2010 Incident Report timed at 5:00 a.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall while getting out of bed with no staff present at the time. This Report documented that staff had heard the personal protectection alarm sound, and when they responded, observed the resident on the floor. Upon assessment, a small amount of bleeding from the left nostril was noted, and a 1 inch in diameter raised area was noted on the resident's left frontal hairline. The resident's left cheek and eye were red and swollen, with an eyeball hemorrhage noted in the outer aspect of the eye, and the right knee was red with an abrasion. This resident received Coumadin anticoagulant drug therapy. A 04/30/2010 Incident Report timed at 7:00 p.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall, with staff outside of the resident's room in the hallway at the time of the fall. This Report documented that the resident had gotten up out of the wheelchair by herself, with the personal protection alarm in place, and had slid to the floor. A 06/05/2010 Incident Report timed at 7:00 p.m. documented that Resident #2 had experienced a fall to the floor, with no staff present at the time of the fall. This Report documented that staff heard the alarm sound, and upon arriving in the resident's room, noted the resident sitting on the floor near the bed. A 06/22/2010 Incident Report timed at 2:00 p.m. documented that Resident #2 had experienced a fall to the floor when she had wandered into the neighbors room and was attempting to take herself to the bathroom. This Report documented that no staff were present at the time of the resident's fall, and that the resident's personal protection alarm had sounded. A 06/25/2010 Incident Report timed at 11:50 a.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall, with no staff present at the time. This Report documented that the resident was in the hallway in front of the dining room waiting to eat lunch when staff heard the resident's personal protection alarm sound. The Report further documented that when staff responded, they observed the resident on the floor in front of the wheelchair. A 07/15/2010 Incident Report timed at 7:50 p.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall by rolling off the bed, in the absence of staff. A Nurse's Note dated 07/16/2010 at 7:45 a.m., and labeled as a late entry, documented that the resident had an unwitnessed fall on 07/15/2010 at 7:50 p.m., and that the resident stated she had bumped her head. This note documented that neurologocal checks were initiated. A 08/13/2010 Incident Report timed at 4:30 p.m. documented that Resident #2 had been found on the floor, having experienced an unwitnessed fall while trying to get out of bed in the absence of staff. Based on the above, the facility had identified Resident # 2 to be at risk for falls, with a 01/11/2010 Resident Care Plan entry identifying this risk and Approaches to address the risk, which included the use of a personal protection alarm at all times. However, the resident experienced ten (10) subsequent falls between 03/30/2010 and 08/13/2010 from the bed, the wheelchair, or while ambulating, with the 04/28/2010 fall resulting in the resident striking the head, causing a raised area on the hairline, left cheek and eye swelling, and an eye ball hemorrhage. The specific falls of 03/30/2010, 04/03/2010, and 04/07/2010 occurred while the resident was not wearing the personal protection alarm, as specified by the Resident Care Plan. The facility failed to ensure adequate supervision of the resident by failing to utilize the personal protection alarm. Additionally, review of the Resident Care Plan revealed an updated entry of 03/16/2010 indicating the resident was on the wheelchair positioning program. However, the specific falls of 04/30/2010 and 06/25/2010 occurred while the resident was in the wheelchair, after the initiation of this 03/16/2010 intervention. But, further record review, to include review of the Resident Care Plan, revealed no evidence to indicate that the facility had reassessed and revaluated the resident to identify additional interventions to address the resident's continued falls from the wheelchair, or to identify additional interventions to address the resident's continued falls from the bed and while ambulating. Based on the above, the facility failed to adequately monitor and utilize a personal protection alarm, as specified by the Resident Care Plan of Resident #2, who received Coumadin anticoagulant drug therapy, to ensure the provision of the necessary supervision and assistance to minimize falls from the bed, from the wheelchair, and during ambulation. The facility also failed to appropriately reevaluate Resident #2 to develop effective interventions to address the resident's continued falls, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, and the resident continued to experience falls, including one fall which resulted in injury. 2. Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment of 09/09/2009 which documented that the resident had been admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had problems with short-term and long-term memory, had moderately impaired cognitive skills for daily decision-making, had needed limited assistance, with the physical assistance of one person, while walking in the room and in the corridor, and had needed limited assistance, with the physical assistance of one person, with transfers. This MDS also indicated that the resident had an unsteady gait. An MDS assessment of 03/10/2010 indicated that Resident #1 continued to have problems with short-term and long-term memory, but indicated that the resident's cognitive skills for daily decision making had become severely impaired at that time. This MDS also indicated that the resident had continued to need limited assistance, with the physical assistance of one person, while walking in the room and in the corridor, but indicated that the resident now needed extensive assistance, with the physical assistance of one person, for transfers. This MDS indicated that the resident continued to have an unsteady gait. The resident's Resident Care Plan contained an entry, originally dated 09/09/2009, which identified that Resident #1 was at risk for falls related to a history of falls and a cognitive deficit. This Care Plan identified multiple Approaches to address this resident's risk for falls, including to provide the limited assistance of one person with ambulation and transfers, to monitor the resident's gait and to provide more assistance as needed. Care Plan Approaches also included the use of a bed alarm to alert staff of any attempts of the resident to rise from bed without assistance, although a 02/05/2010, 9:30 a.m. Nurse's Notes Quarterly Review indicated that the resident had utilized a bed alarm in the past, but that it had been discontinued at that time. Additionally, the resident's July 2010 physician's orders [REDACTED]. This physician's orders [REDACTED].#1 received the anticoagulant aspirin, 81 milligrams (mgs.) daily. A Nurse's Note of 03/09/2010 at 1:50 a.m. documented that Resident #1 was found on the floor beside the bed, sitting with his/her back against the bed. This Note documented that the resident stated he/she had been to the bathroom and was returning to her bed when she fell . An Incident Report of 03/09/2010 timed at 1:50 a.m. also documented this fall, and documented that no staff was present at the time of the fall. A Nurse's Note of 03/30/2010 at 2:30 p.m. documented that Resident #1 was found on the floor in the common area bathroom, lying on the left side. This Note documented that the resident stated she had stumbled and fell and had hit her head on the wall. This Note further documented that staff had performed neurological checks on the resident. An Incident Report of 03/30/2010 timed at 2:15 p.m. also documented this fall, and documented that no staff was present at the time of the fall. A Nurse's Note of 04/07/2010 at 6:15 p.m. documented that a certified nursing assistant (CNA) had reported Resident #1 on the floor, with the resident found lying on the right side. This Note further documented that the resident stated she was getting a bag of clothes off the roommates bed, lost her balance, and fell to the floor. An Incident Report of 04/07/2010 at 6:15 p.m. also documented this fall, and further documented that the resident had been found on the floor, with this being an un-witnessed fall. A Nurse's Note of 04/14/2010 at 8:30 p.m. documented that Resident #1 was sitting in the common area in a recliner. This Note documented that a CNA reported seeing the resident leaning over, and before the CNA could get to the resident, the resident had fallen to the floor on her left side. This Note further documented that the resident was assessed to have a reddened area on the left forehead, and that neurochecks were initiated. A Nurse's Note of 04/19/2010 at 6:30 p.m. documented that a CNA had gone by the resident's room door, heard the resident moaning, and found the resident on the floor in the bathroom. This Note documented that the resident was assessed and was noted to have a reddended area on the posterior scalp, and that neurological checks were initiated. An Incident Report of 04/19/2010 timed at 6:30 p.m. also documented this fall, and further documented that no staff was present at the time of this unwitnessed fall. A Nurse's Note of 05/08/2010 at 3:30 a.m. documented that Resident #1 was found sitting on the floor beside the bed. This Note documented the resident stated she was sitting on the side of the bed, tried to get up, and then fell to the floor. An Incident Report of 05/08/2010 timed at 3:23 a.m. documented that no staff was present at the time of this unwitnessed fall. A Nurse's Note of 05/21/2010 at 3:30 p.m. documented that staff had found Resident #1 on the floor in the bathroom, having bumped her head on the floor causing a hematoma. This Note further documented that neurological checks were initiated. An Incident Report of 05/21/2010 timed at 3:30 p.m. also documented this fall, and indicated that the resident was found on the floor in the common bathroom. This Report documented that a two-and-one-half ( 2 1/2) centimeter (cm.) by four (4) cm. hematoma was noted in the center of the resident's forehead, and documented that no staff was present at the time of this unwitnessed fall. This resident received aspirin anticoagulant drug therapy. A Nurse's Note of 05/25/2010 at 4:25 p.m. documented that Resident #1 went into the common area bathroom, staff heard a noise, and upon entering the bathroom, observed the resident laying on the left side near the toilet. An Incident Report of 05/25/2010 timed at 4:25 p.m. document this fall, and documented that no staff was present at the time of this unwitnessed fall. A Nurse's Note of 06/14/2010 at 2:10 p.m. documented that Resident #1 was found on the floor between the doorway of another resident's room in the hallway lying on the left side. This Note documented that the resident stated that she had hit the left side of her head on the floor, and documented slight redness upon assessment. This Note further documented that neurological checks were initiated. An Incident Report of 06/14/2010 timed at 12:35 p.m. also documented this fall, and documented that no staff was present at the time of this unwitnessed fall. An Incident Report of 06/29/2010 timed at 9:00 p.m. documented that Resident #1 had been found on the floor. This Report documented that the resident stated she was going to bed, sat too close to the edge, and slipped down to the floor. This Report documented that no staff was present at the time of this unwitnessed fall. A Nurse's Note of 07/01/2010 at 9:30 a.m. documented that Resident #1 was found on the floor in the dining room, sitting on the buttocks. An Incident Report of 07/01/2010 timed at 9:30 a.m. also documented this fall, and documented that no staff was present at the time of this unwitnessed fall. Record review revealed that the facility had initiated, as one specific intervention, a physician's orders [REDACTED].#1 was up in the wheelchair related to unsteady gait with ambulating and decreased safety awareness. However, further record review revealed no evidence to indicate that, after having initially assessed the resident to be at risk for falls and devising Approaches on the 09/09/2009 Resident Care Plan to address this risk, the facility had reevaluated the resident to develop additional interventions related to the eleven (11) subsequent falls the resident sustained [REDACTED]. And, specifically during the falls of 03/30/2010, 04/14/2010, 04/19/2010, 05/21/2010, and 06/14/2010, the resident hit her head, requiring the initiation of neurological checks, with the fall of 05/21/2010 also resulting in a hematoma. Additionally, Nurse's Notes of 03/13/2010 at 10:00 a.m., 03/30/2010 at 4:00 p.m., 04/08/2010 at 10:00 a.m., 04/17/2010 at 10:00 a.m., 04/18/2010 at 10:00 a.m., 04/20/2010 at 10:00 a.m., 05/16/2010 at 1:00 p.m., 06/15/2010 at 1:00 p.m., and 06/30/2010 at 2:00 p.m. documented that Resident #1 ambulated "ad lib". Despite the resident's assessed risk for falls and the Care Plan Approach which specified that staff monitor the resident to ensure the provision of the necessary assistance with ambulation as the resident needed, staff failed to provided the needed assistance with ambulation to the resident. Rather, the resident ambulated "ad lib", resulting in multiple falls, as documented in the above examples. Based on the above, the facility failed to adequately monitor Resident #1, who received aspirin anticoagulant drug therapy, to ensure the provision of the necessary assistance to prevent falls during ambulation and transfers, per the Plan Of Care. The facility also failed to appropriately reevaluate Resident #1 to develop effective interventions to address the resident's continued falls, and thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, and the resident continued to experience falls, including falls resulting in injury. 3. Record review for Resident #7 revealed an MDS of 03/26/2010 which documented a date of entry to the facility of 03/16/2010, and which documented that the resident had [DIAGNOSES REDACTED]. This MDS indicated that the facility had not been able to determine the resident's short-term and long-term memory status at that time, but that the resident had severely impaired cognitive skills for daily decision making, required limited assistance, with the physical assistance of one person, for walking in the room and on the corridor and for transfers, and had an unsteady gait. An MDS of 06/11/2010 documented that at that time, the resident had both short-term and long-term memory problems, and continued to have severely impaired cognitive skills for daily decision making, continued to need limited assistance, with the physicial assistance of one person, for walking in the room and on the corridor and for transfers, and continued to have an unsteady gait. The Resident Care Plan for Resident #7 identified a problem, with an original date of 03/25/2010, of the resident being at risk for falls related to a history of falls, poor cognition, muscle weakness, and an unsteady gait. This Care Plan included, as Approaches to address the resident's risk for falls, for staff to assist the resident with ambulation as needed and tolerated, and for a bed alarm to be used while in bed. An Incident Report dated 03/26/2010 at 6:00 p.m. documented that Resident #7 had fallen in another resident's room after getting out of the wheelchair and trying to sit in the recliner, at which time she slid off the seat and sat onto the floor. This Report documented that no staff were present at the time of the fall. An Incident Report dated 03/27/2010 at 4:00 p.m. documented that Resident #7 had fallen in the common area, in the presence of staff, as she stood up, fell to the knees, then lowered herself to the floor. An Incident Report dated 03/30/2010 at 10:30 a.m. documented that Resident #7 fell , in the presence of staff, while in the common area. This Report documented that the resident had attempted to sit in another resident's wheelchair, and had then slid to the floor. An Incident Report dated 03/30/2010 at 4:45 p.m. documented that Resident #7 had fallen, in the presence of staff, while in the common area as the resident started to get up from a recliner, slid forward, and then slid out of the chair. An Incident Report dated 04/07/2010 at 2:00 p.m. documented that Resident #7 had fallen, with no staff present, while ambulating ad lib in the common area. This Report documented that the resident sustained [REDACTED]. by four (4) cm. hematoma to the posterior head. This resident received aspirin anticoagulant drug therapy. An Incident Report dated 04/10/2010 at 9:00 a.m. documented that Resident #7 had fallen while in the presence of staff. This Report further documented that the resident was in the dining room ambulating ad lib when she lost her balance and before staff could respond, she fell to the floor. An Incident Report dated 04/12/2010 at 08:30 a.m. documented that Resident #7 had fallen, in the absence of staff. This Report documented that the resident was found sitting on the floor in the dining area, and that the resident was receiving an 81 mg. dose of the anticoagulant aspirin at the time of this fall. An Incident Report dated 04/15/2010 at 5:45 p.m. documented that Resident #7 had fallen in the common room, in the presence of staff, as she was transfering from one chair to another. This Report documented that as the resident attempted to sit in the chair, she lost her balance and fell to the floor, and bumped her posterior head on the wall. An Incident Report dated 04/18/2010 at 4:00 a.m. documented that the resident's bed alarm had sounded, and when the CNA responded, the CNA observed the resident lying on the floor between the bed and the wall. An Incident Report dated 05/16/2010 at 2:15 p.m. documented that Resident #7 had experienced an unwitnessed fall in the absence of staff. This Report documented that upon entering the resident's room, the charge nurse observed the resident sitting on the floor between the bed and the wall, leaning on the bed. This report also documented that upon assessment, a red/purple area on the lower back of the resident's right hip was noted, and documented that the resident was receiving an 81 mg. dose of the anticoagulant aspirin at the time of this fall. An Incident Report of 05/31/2010 at 7:20 a.m. documented that Resident #7 had experienced an unwitnessed fall in the absence of staff. This Report documented that the resident was found on the floor, sitting beside the bed. The Report also documented that the resident had sustained a skin tear to the right elbow, which was cleaned and dressed. An Incident Report of 06/04/2010 at 2:10 p.m. documented that a facility nurse was walking down the hallway and noted Resident #7 sitting on the floor in front of the recliner in her room. An Incident Report of 06/18/2010 at 7:20 a.m. documented that Resident #7 had experienced an unwitnessed fall, with no staff present. This Report documented that staff had notified the charge nurse that the resident was on the floor. Upon entering the room, the charge nurse noted the resident on the floor with her head propped against the bed stand. The Report further documented that upon assessment, the nurse noted a hematoma on top of the resident's head, and noted that neurological checks were initiated. This resident was receiving aspirin anticoagulant drug therapy. An Incident Report of 07/11/2010 at 7:00 a.m. documented that Resident #7 had experienced an unwitnessed fall, with no staff present. This Report documented that the CNA notified the charge nurse that the resident was on the floor, and that the charge nurse noted the resident to be laying on the floor in the hallway on his/her left side. This Report documented that the resident was receiving an 81 dose of aspirin at the time of this fall. An Incident Report of 07/13/2010 at 1:00 p.m. documented that Resident #7 had fallen to the floor in the absence of staff while in the dining room ambulating ad lib. An Incident Report of 07/21/2010 at 7:45 p.m. documented that while housekeeping staff was in the vicinity, Resident #7 was sitting in the recliner in the common room, slid forward to get up, and fell between the chair and couch. This Report documented that the resident sustained [REDACTED]. An Incident Report of 07/26/2010 at 5:15 a.m. documented that the charge nurse entered the room of Resident #7 due to hearing the resident's roommate yelling for help. This Report documented that the resident was observed sitting on the floor beside the roommates bed. An Incident Report of 08/22/2010 at 10:50 a.m. documented that CNAs reported that while in the common area, Resident #7 had slipped out of the recliner and fallen to the floor as she was attempting to sit in the recliner by another resident. This Report documented that the resident was receiving an 81 mg. dose of aspirin at the time of this fall. The facility had identified Resident #7, who received aspirin anticoagulant drug therapy, to be at risk for falls, with a 03/25/2010 Resident Care Plan entry identifying this risk and Approaches to address the risk. However, the resident experienced fourteen (14) subsequent falls between 03/26/2010 and 08/22/2010 from the recliner or while ambulating, with the resident hitting her head during the specific falls of 04/07/2010, 04/15/2010, and 07/21/2010, sustaining a hematoma to the head during the fall of 04/07/2010 and a laceration to the head during the fall of 07/21/2010. There was, however, no evidence to indicate that the facility evaluated the resident for continued falls from the recliner and while ambulating after the initial assessment of 03/25/2010. Additionally, the resident experienced a fall from the bed on 04/18/2010, resulting in the addition of a low rise bed on 04/27/2010 and the discontinuation of the use of the bed alarm on 05/07/2010, as documented in entries to the Resident Care Plan. The resident then experienced another fall from the bed on 05/16/2010, but there was no evidence to indicate that the facility reassessed and reevaluated the resident after this fall from the bed to identify interventions to minimize further falls, and the resident thus sustained two (2) subsequent falls from the bed, on 05/31/2010 and 06/18/2010, with the resident hitting her head and sustaining a hematoma to the head during the fall of 06/18/2010. Based on the above, the facility failed to adequately monitor Resident #7, who received aspirin anticoagulant drug therapy, to ensure the provision of the necessary supervision and assistance to prevent falls from the recliner, from the bed, or during ambulation, and failed to to appropriately reevaluate the resident to develop effective interventions to address the resident's continued falls. The facility thus failed to assure the provision of the necessary assistance and supervision to minimize the resident's continuing to sustain falls, and the resident continued to experience falls, including falls resulting in injury. 4. Record review for Resident #8 revealed an Admission MDS of 12/30/2008 which documented the resident had been admitted to the facility on [DATE]. An MDS of 06/16/2010 indicated that the resident had [DIAGNOSES REDACTED]. The Resident Care Plan for Resident #8 identified, as an entry originally dated 09/28/2009, that the resident was at risk for falls related to cognitive deficit and an unsteady gait, with Approaches which included the use of a wheelchair for locomotion, responding promptly, and keeping the call light within easy reach, even though this Care Plan also noted that the resident's cognition might be such that she could not use the call light. This Care Plan referenced additional Approaches, also dating from 09/28/2009, specifying the application of a bed alarm to the bed and the application of a patient protector alarm while out of bed, but a notation on the Care Plan documented that these Approaches had been discontinued on 02/15/2010. The Care Plan for falls also referenced an entry dated 05/31/2010 which specified the use of a left half-rail for bed mobility. An Incident Report dated 07/17/2010 at 10:05 p.m. documented that Resident #8 had sustained an unwitnessed fall to the floor in her room, with no staff present at the time of the fall. An Incident Report dated 07/22/2010 at 5:35 p.m. documented that Resident #8 had sustained a witnessed fall to the floor in the common area, with staff present at the time of the fall. This Report documented that the resident had rolled the wheelchair up to the back door, leaned over too far, tumbled forward and fell out of the chair. An Incident Report dated 08/04/2010 at 2:45 a.m. documented that Resident #8 had sustained an unwitnessed fall to the floor in the bathroom, with no staff present