Every finding on record at Orlando Health Center for Rehabilitation

Based on interview, and record review, the facility failed to report an allegation of neglect to the State Agency, (#1) and failed to report timely an allegation of neglect, (#3), for 2 of 2 residents reviewed for abuse, of a total sample of 7 residents. Findings: 1. Review of resident #1's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. She had diagnoses of dementia, fracture of neck of left femur, wedge compression fracture of the first lumbar vertebra, unsteadiness in her feet, and aftercare joint replacement surgery. Review of resident #1's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 2/28/24 revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated she was cognitively impaired. The MDS assessment noted no rejection of evaluation or care necessary to obtain goals for her health and well-being. The MDS showed resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sitting on side of bed. She required partial/moderate assistance for chair/bed-to-chair transfer and toilet transfer. Review of the Agency for Health Care Administration (AHCA) Nursing Home Adverse Incident Report submitted on 12/01/23 revealed the following information: resident #1 was observed sitting on the floor in the dining area on 11/18/23 at approximately 5:30 PM and was assisted up by two Certified Nursing Assistants (CNAs). The report noted the assigned nurse was close by and witnessed staff assist the resident. The CNAs and the nurse acknowledged the event as the resident's common behavior with no follow up documentation or assessment done by the assigned nurse. At approximately 9:00 PM on the same day, resident #1's assigned CNA went to check on her and found her lying on her left side on the floor in her room. The report indicated the nurse was notified and resident #1 was assisted back to bed by two CNAs. The nurse and CNAs didn't think the resident fell but purposely laid on the floor, and viewed the incident as the resident's known behavior. No follow-up documentation was found in the resident's medical record. Incidents were not reported during the change of shift at 11:00 PM to the following shift. At approximately 4:00 AM on 11/19/23 during care, resident #1, Was making sounds like pain, but the CNA was unsure because resident #1 had similar known behaviors when she wanted to be left alone. On 11/19/23 at approximately 12:00 PM, the CNA notified the nurse resident #1 was crying out when she attempted to assist her with care. The nurse evaluated the resident and observed a yellowish discoloration to her left hip. She noted resident #1 had pain and notified the physician. An x-ray of the left knee, hip and femur were ordered, and the results revealed she suffered a fracture of the left femur. The resident was transferred to the hospital and underwent left hip replacement surgery. The Analysis of the Incident Section listed: Failure to follow the protocol for falls, resulted in inadequate assessment of resident; lack of appropriate interventions that could have minimized the risk of fall with major injury; failure to follow protocol for change of condition, resulted in not notifying the physician for orders and competency regarding documentation. On 5/02/24 at 5:05 PM, the Risk Manager explained the nurse's statement indicated the resident's gait was off and the resident was found again on the floor but there was no subsequent documentation or follow up in the medical record. The Risk Manager stated the nurse did not follow the fall protocol. The Administrator and Risk Manager explained the incident was an unwitnessed fall which they did not consider neglect even though the nurse did not follow the proper fall protocol including assessment, notification, and documentation. 2. Review of resident #3's medical record revealed he was admitted to the facility on [DATE] with diagnoses including syncope and collapse, dementia, type 2 diabetes, and fall. Review of resident #3's MDS quarterly assessment with ARD of 11/01/23 revealed a BIMS score of 99, which indicated he was unable to complete the interview. Review of the medical record revealed resident #1 had a care plan for elopement risk/wanderer related to history of attempts to leave the facility unattended, and impaired safety awareness initiated on 5/19/23. The goal was the resident's safety would be maintained. Resident #3 also had a care plan for risk for falls and injuries from falls related to unsteadiness at times, impaired cognition, history of syncope and collapse initiated on 5/10/23. Review of AHCA's Nursing Homes Federal Reporting submitted on 11/29/23 revealed an allegation of neglect related to resident #3 occurred on 11/27/23 at 9:30 AM. The report indicated resident #3 was sent to a medical appointment via transport without an escort. The Department of Children and Families (DCF) was notified on 11/29/23. The Administrator and Director of Nursing (DON) reported it was standard practice to send an escort with the resident to appointments unless family or guardian was in attendance. On 5/02/24 at approximately 5:30 PM, the Administrator explained he was contacted by the former DON at approximately 6:40 PM on 11/27/23, and told resident #3 had not returned from his cardiac appointment that the morning. The Administrator stated he went to the doctor's office and found resident #3 at approximately 7:15 PM sitting in the main lobby by himself. He stated he spoke with the physician's office the following day and learned the appointment was supposed to be a telehealth visit. He explained when resident #3 arrived at the appointment, they tried to accommodate him for a later appointment time. He indicated transport came to pick him up, but he was not ready since he was still waiting to be seen by the physician. He stated transport arrived a second time, but the resident was being seen at the time by the provider and they left. He explained after resident #3 was seen by the physician, the physician's office tried to call the facility to inform them resident #3 was ready for pick up but the face sheet used at the time had only the facility name, not their address or phone number. He stated the physician's office searched the facility online but called a different facility with a similar name and were told there was no one by resident #3's name. The Administrator acknowledged resident #3 spent over 9 hours without supervision, food, or medications until he was picked up and could have gotten lost or into an accident. Later at 6:56 PM, the Administrator stated he could not say why the facility did not file a report with AHCA within 24 hours as required. On 5/02/24 at approximately 5:40 PM, the Risk Manager stated she was unable to determine when the immediate report to AHCA was filed. Later at 6:58 PM, she stated she could not recall why the facility did not report timely. On 5/02/24 at 6:48 PM, the DON stated she was the Abuse Coordinator but was not working in the facility when resident #3's incident occurred. She explained an allegation of abuse must be reported within 2 hours to AHCA, DCF and law enforcement. She stated an allegation of neglect without injury was to be reported within 24 hours. The DON stated neglect was the failure to provide goods and services needed for the safety and well-being of a resident. Review of the facility Abuse Prevention Program policy and procedure not dated read, All reports of resident abuse, neglect exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The procedure included notification to the designated agencies in accordance with state law. It read, All alleged violations involving abuse, neglect exploitation or mistreatment, including and/or injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse that result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (Including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The policy mentioned the Administrator had the overall responsibility for the coordination and implementation of the facility's abuse prevention program policies and procedures.

Based on observation and interview, the facility failed to discard expired food in the kitchen. Findings: On [DATE] at 11:20 AM, a tour of the kitchen was conducted with the Dietetic Technician, Registered. The dry food storage had four single serving 7.25-ounce cans of chicken noodle soup with an expiration date of [DATE]. Below those four cans was another carton containing 24 single serving 7.25-ounce cans of cream of chicken soup with the same outdated expiration date. The Dietetic Technician stated they do not really use that supply and instructed a dietary aide to discard the expired soups. On [DATE] at 9:37 AM, the Dietetic Technician stated the cans of soup were discarded and the others were checked for expiration dates. She explained the soups were single serving cans and only used if a resident requested soup. She acknowledged she could not be absolutely certain whether or not any of the expired soups had been used since the expiration date. Review of the United States Food and Drug Administration (FDA) Food Code 2017 documented, Manufacturer's use-by dates is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. The manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

Based on observation, interview, and record review, the facility failed to provide timely assessments and treatments for therapy services for 1 of 1 resident reviewed for rehabilitation and restorative services from a total sample of 20 residents, (#239). Findings: Review of the medical record revealed resident #239 was admitted to the facility on [DATE] from a skilled nursing facility with diagnoses including dysphagia (difficulty swallowing), repeated falls, difficulty in walking, cognitive communication deficit, and Alzheimer's disease. The Minimum Data Set (MDS) admission comprehensive assessment with Assessment Reference Date 4/16/2023 identified the resident was unable to complete the Brief Interview for Mental Status and noted the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any rejection of evaluation or care necessary for health and well-being. He required extensive staff assistance to eat and complete activities of daily living and was totally dependent on staff for transfers, locomotion, toilet use, and bathing. The assessment showed there were no special treatments for Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), or Restorative Nursing services provided during the look back period. The care plan completed 4/10/2022 included a Therapy Plan of Care for PT, OT, and ST services. Review of the Physician's Order Summary Report included physician's orders for PT, ST, and OT to evaluate and treat as needed dated 4/13/2023. Review of the therapy progress note dated 4/11/23 and 4/25/23 showed Speech Language Pathologist (SLP) A completed a note that a speech therapy screening had been completed and that a further ST evaluation was required. On 4/25/2023 at 9:06 AM, the resident was observed in the memory care unit common area sitting in a wheelchair at a table being assisted by staff to eat his breakfast. The resident was noted to be coughing while attempting to eat. On 4/27/2023 at 10:30 AM, SLP A said she completed resident #239's speech therapy screen on 4/11/2023 and determined the resident required further evaluation. She stated she completed the evaluation on 4/25/2023 when she observed the resident coughing while swallowing medications and eating. She explained she was concerned the resident had a high risk for aspiration, and she recommended a downgrade of his food texture to mechanically altered on 4/25/23. She explained an unidentified decline in residents' swallowing abilities could cause aspiration pneumonia. She explained she typically completed resident evaluations within 2 days after screening, and she did not explain why resident #239's evaluation was delayed for 14 days. She conveyed it was best clinical practice to complete them, right away. A review of the therapy progress notes showed resident #239 was screened for Physical Therapy on 4/25/23, twelve days after the physician's order. The screening noted a further evaluation was required. The record did not show an Occupational Therapy screening assessment was completed. On 4/26/2023 at 10:06 AM, the Director of Rehabilitation stated all physician orders for admission screening assessments for PT, OT, and ST were expected to be completed within 48 hours. She explained any screening that indicated further evaluation was required should have been completed within 1 day. She acknowledged resident #239's therapy care services were completed late. She said residents were at risk for decline when care and services were delayed. Review of the facility's policies and procedures titled, Functional Impairment - Clinical Protocol, dated revised September 2012, read, 1. Upon admission to the facility . staff will assess the resident's physical condition and functional status. Review of, Resident Screening (5006) document #88 read, 1. The screening procedure will be performed and documented within 2 working days of admission.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and a safe environment in the locked Memory Care Unit to prevent a physically and cognitively impaired resident from suffering falls with major injuries, for 1 of 5 residents reviewed for falls, of a total sample of 7 residents, (#1). These failures contributed to multiple unwitnessed falls, serious injuries, and the resident's subsequent death. There was likelihood resident #1 suffered excruciating pain as a result of her bone fractures, and she required sedation to control her symptoms of pain and extreme agitation at the end of her life. On [DATE] at approximately 5:00 PM, resident #1 was left unattended on the outdoor patio of the Memory Care Unit. While repeatedly walking around a planter at the edge of the paved area, she fell hard to the ground and rolled out onto the grassy area adjacent to the patio. The resident sustained a fracture of the left clavicle with extensive bruising and swelling due to bleeding under the skin. Over the next six weeks, resident #1 suffered three unwitnessed falls, two injuries of unknown origin source, and an incident with a male resident who pulled her backwards across the floor by the collar of her blouse. On [DATE], resident #1 was noted with swelling and discoloration of her left arm. X-rays showed a fracture of the left elbow and a possible fracture of her left wrist. On [DATE] at approximately 4:30 AM, resident #1 was found on the floor in her room after another unwitnessed fall. This incident resulted in a fracture of the left hip. The resident was not a candidate for necessary hip repair surgery, and was referred to hospice for end-of-life services. She died on [DATE], five days after her last fall. There were 29 physically and cognitively impaired residents on the Memory Care Unit. The facility's failure to ensure adequate level of supervision or defined frequency of monitoring and provide an environment that was free of hazards contributed to resident #1's falls, serious injuries, and subsequent death, and placed all residents at risk for falls resulting in serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F741 and F835 Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included dementia, major depressive disorder, anxiety disorder, type 2 diabetes, [CONDITION(S)], and disc degeneration of the neck. The resident's room was located on the A side of the facility's locked Memory Care Unit. The Minimum Data Set (MDS) Quarterly assessment with assessment reference Date (ARD) of [DATE] revealed resident #1 had unclear speech, was rarely or never understood, and rarely or never understood others. Her vision was impaired, and she required glasses. Staff assessment of the resident's mental status indicated she had short-term and long-term memory problems, and severely impaired cognitive skills for daily decision making. During the MDS assessment lookback period, resident #1 exhibited wandering behavior daily. She required extensive assistance with bed mobility, and transfers, but walked independently, without a mobility device. The document revealed during position changes from seated to standing and surface to surface transfers, resident #1 had unsteady balance and was only able to stabilize with staff assistance. The MDS assessment showed her balance was also unsteady during walking, turning around, and moving on and off the toilet, but she was able to stabilize without staff assistance. The document reflected one fall with major injury since the prior assessment. Review of resident #1's medical record revealed an Alert Note dated [DATE] at 5:05 PM, written by the Weekend Nursing Supervisor. The note indicated she observed the resident seated in a chair on the patio with dirt on left side of her face, on her knees and the arms of her sweater. The note revealed prior to this discovery, resident #1 had been inside the Memory Care Unit, walking rapidly with a shuffling and unsteady gait. Later that evening, on [DATE] at 9:49 PM, another Alert Note showed resident #1 developed a purple-colored swelling to the area below her neck that extended down to her left breast. On [DATE] at 2:06 PM, the facility's Risk Manager (RM) provided video footage of resident #1's fall on the patio on [DATE]. She explained the quality of the footage was not good as it froze at times, and the timestamp might not be accurate. Review of recorded video footage which was dated and timestamped Sunday, [DATE] at 4:52:33 PM, showed resident #1 as she exited the unlocked sliding doors of the Memory Care Unit and walked onto the outdoor patio. There were no staff noted in the area and resident #1 was not wearing her glasses. The resident crossed the patio and began to walk around a large planter located close to the edge of the paved area. As she walked on the narrow, paved area behind the planter, she fell , landed hard on the ground, and then rolled out onto the grass. Resident #1 then sat up, looked around, and after a few minutes was able to stand by getting onto her hands and knees and pushing herself up off the ground. She returned to the patio, walked around the same planter twice, and then crossed the patio to sit in a chair. The segment of video footage provided by the facility did not show how long the resident was outside unnoticed by staff, or whether she had any other incidents before she was discovered. A Health Status Note dated [DATE] at 8:42 PM, revealed resident #1 returned to the facility from the hospital with a diagnosis of fractured left clavicle and a sling to support her left arm during the healing process. A Change in Condition Follow-Up note dated [DATE] at 1:10 PM, written by the Memory Care Licensed Practical Nurse (LPN) Unit Manager (UM), reviewed resident #1's fall on the patio. The UM wrote Resident has a history of falls due to impaired gait, age related visual deficits, behaviors of impulsiveness with over estimating her self limitations due to diagnosis of dementia. The document indicated the resident was mostly non-verbal and could not explain any details surrounding the incident. The UM's documentation revealed resident #1's care plan was reviewed, interventions were in place, and a fall risk evaluation was completed. A Health Status Note dated [DATE] at 1:21 AM, revealed resident #1 continued to ambulate around the Memory Care Unit with her left arm behind her back, not supported in the sling as required. The care plan for risk for falls, initiated on [DATE], revealed resident #1 walked at a fast pace and had impaired posture which increased her risk for falls. The document noted the resident also enjoyed walking outside on the patio and in the grass. The care plan goal noted resident #1 would not sustain serious injuries from falls. Interventions in place prior to the resident's fall on [DATE] included anticipate and meet her needs, stop her when noted to be walking fast, redirect her to slow down, and remind her to wear her glasses. New care plan interventions on [DATE] directed staff to remain outside when the resident was outside and encourage her not to walk on the grass alone. However, the care plan did not reflect any new approaches regarding increased supervision and monitoring of resident #1. The care plan did not address her increased risk for falls due to her continued lack of safety awareness combined with additional challenges with balance and ambulation caused by the left clavicle fracture and use of a sling. A post fall Fall Screening tool dated [DATE] deemed resident #1 to be at moderate risk for falling with a score of 40. The evaluation was inaccurate as it showed resident #1 required assistance form nursing staff rather than independent ambulation and use furniture for support. The document also indicated the resident had normal gait and knew the limits of her abilities, contrary to MDS assessment findings and her care plan. Another Fall Screening tool completed on [DATE] remained inaccurate with the exception of identifying the resident overestimated or forgot her limits. The fall risk score increased to 55, which deemed her high risk for falling. A Change of Condition note dated [DATE] at 5:25 PM revealed resident #1 was found on the floor in a male resident's room on the B side of the unit, with no apparent injury. Although the fall was unwitnessed by staff, the possible cause was noted as lost balance. An associated Behavior Note dated [DATE] at 5:48 PM, indicated the male resident who lived in the room where resident #1 was found on the floor stated he punched her. The fall care plan was updated on [DATE] to instruct staff to redirect her from the B side of the unit. This approach was not new as it was initially added to the care plan on [DATE]. The care plan did not reflect revisions regarding closer supervision of the resident's activities to mitigate fall risk factors. Review of the post-incident Fall Screening tool revealed the resident's score increased from 55 to 105. A Change of Condition note dated [DATE] at 9:54 PM revealed resident #1 had another unwitnessed fall. Nursing staff surmised . she apparently lost her balance and fell . The resident suffered a scrape to the right knee. Later that night another Change of Condition note dated [DATE] at 10:01 PM, indicated a Certified Nursing Assistant (CNA) noticed resident #1 had skin discoloration to her left lower buttock, which nursing staff attributed to resident may have sat quickly on a hard surface. The fall risk care plan was updated on [DATE] to reflect staff will continue to redirect resident away from others personal space. This intervention was already noted twice on the document and although proven ineffective, was added again. The care plan still did not direct nursing staff to increase the level of supervision or designate the frequency of monitoring necessary to prevent repeated falls. Review of the post-incident Fall Screening tool revealed the resident's score remained 105. Review of the facility's incident log revealed on [DATE] at approximately 7:00 AM, resident #1 was observed on the floor on the B side of the unit. The fall was unwitnessed by nursing staff, but a housekeeper passing by alerted the UM to a male resident who pulled resident #1 backwards on the floor by her collar. Review of resident #1's medical record showed no evidence of interdisciplinary team (IDT) discussion regarding development of any fall prevention interventions after this incident, and the fall care plan was not updated to ensure increased monitoring of her location, status, and activities to avoid further falls. Review of the post-incident Fall Screening tool revealed the resident's score was 105, indicating a high risk for falling. A Change of Condition note dated [DATE] at 11:10 PM, revealed resident #1 had an area of swelling and discoloration noted to her left arm and left hand. The possible cause was deemed possibly from previous fall. A Radiology Report dated [DATE] revealed resident #1 sustained a fracture of the left elbow and a possible nondisplaced fracture of the left wrist. A Health Status Note dated [DATE] at 8:59 PM revealed resident #1 returned from the hospital emergency room with a cast on her left arm, and sling / splint in place that was not be removed by nursing staff. Review of nursing progress notes and staff assignment sheets revealed resident #1 was placed on one to one (1:1) supervision with assigned CNAs to monitor and care for her 24 hours daily from [DATE] to [DATE]. Review of the facility's incident log and the resident's medical record showed resident #1 wore the left arm sling as required, and had no falls, no injuries of unknown origin, and no incidents or altercations involving other residents during the period of 1:1 supervision. Resident #1 was assessed for Physical Therapy (PT) services while on 1:1 supervision. The Physical Therapy Plan of Care showed a start of care date of [DATE] for a treatment diagnosis of unsteadiness on the feet. The document indicated the nursing department initiated the PT referral as resident #1 needed more assistance to ambulate safely. The reason for the referral was resident #1 had a deficit in standing balance and strength over the previous few weeks due to a recent fall with left clavicle fracture and continued use of a left arm sling. Physical Therapist F completed the initial assessment on [DATE] and noted the resident required supervision or touching assistance for transfers, and standby assistance or supervision for standing balance. Resident #1 was able to walk 50 feet with handheld physical assistance. Physical Therapist F's evaluation revealed resident #1 was not oriented to person, time, or place, was at high risk for falls, required both upper extremities to support herself without assistance and had a moderately forward-flexed trunk. Review of a PT Daily Treatment Note dated [DATE] revealed Physical Therapist F instructed the CNA to use a gait belt while ambulating with resident #1. A gait belt is a safety device used to help patients with transfers or to hold them upright and steady while ambulating. The gait belt provides support and helps to prevent falls (retrieved on [DATE] from www.drugs.com). On [DATE], Physical Therapist E noted resident #1 walked 150 feet with handheld assistance but lost her balance when she tripped on her own feet. On [DATE], Physical Therapist E noted resident #1 still required handheld assistance during ambulation. A Change of Condition note dated [DATE] at 4:40 AM, ten days after resident #1's level of supervision was changed from 1:1 to standard monitoring, reported she had an unwitnessed fall in her room. The document indicated the possible cause was Resident attempted to self transfer out of bed without assistance. She was evaluated by nursing staff who found she could neither extend nor bear weight on her left leg. The MDS Discharge assessment - Return Anticipated with ARD of [DATE] revealed resident #1 had an unplanned discharge to an acute hospital. The document indicated she still had memory problems, severely impaired cognition, and daily wandering behavior. The MDS assessment revealed during the lookback period, the resident no longer walked independently, instead she required extensive assistance. Resident #1 did not have a terminal prognosis with life expectancy of less than 6 months. The MDS assessment indicated resident #1 had one fall with no injury, one fall with injury and one fall with major injury in the three-month period since the prior assessment. The document showed the resident received PT services from [DATE] to [DATE]. On [DATE] at 3:34 PM, during a telephone interview, resident #1's son recalled in February 2022, the facility notified the family that their mother fell while she was outside on the patio, but staff did not know the circumstances. He explained he visited the facility and discovered his mother was severely bruised from her neck to her waist. The son stated they transported their mother to the hospital where she was found to have a left clavicle fracture. He stated the family then submitted a written request to the facility for a meeting regarding their mother's care. The son recalled during the meeting the family was made to feel as if the discussion was unnecessary as the facility was taking good care of their mother. He said, I got the feeling they were not as concerned as we were. The son stated the facility refused to provide video footage of their mother's fall on the patio. He confirmed he openly expressed concerns regarding the Memory Care Unit's numerous tripping and fall hazards for residents with dementia, especially on the outdoor patio. He stated his mother had another fall which resulted in a second fracture, and he was again told staff did not know what happened. The son added that soon after, the facility called the family to inform them of an incident involving his mother being dragged across the floor by another resident. Resident #1's son became emotional and tearful as he expressed frustration that all the incidents and injuries occurred without staff present. He said, I can't understand why every time the facility called to say mom fell , nobody could explain how it happened, because nobody ever saw anything. The son verified after his mother's second fracture the facility informed the family she would have designated staff members to watch her 24 hours daily. He confirmed during a Mothers' Day visit on Sunday, [DATE], his mother had a CNA assigned to her. However, he explained the family received a call from the facility during the following week to notify them his mother had another fall, and she was found on the floor in her room. The son said, Therefore, there was not a nurse with my mom. We found out they took it on themselves to take away the 24-hour care after Mothers' Day. They never notified us that they did that. The son stated his mother did not fall during the entire time she had continuous monitoring and he did not understand why she would have been left alone. On [DATE] at 4:03 PM, during a telephone interview, resident #1's daughter stated the UM was unable to explain how her mother fell and fractured her clavicle on the outdoor patio in February 2022. She explained her mother had numerous falls and incidents in the Memory Care Unit, and after a second fall-related fracture in [DATE], the facility implemented 1:1 supervision. The daughter recalled on the morning of [DATE], the UM called her to explain that her mother had fallen again and was not able to bear weight on her leg. She stated she discovered the facility had previously removed her mother's 1:1 supervision and said, Nobody told us they would take it away. The daughter explained her mother sustained a left hip fracture from that fall and experienced significant pain from the injury. She recalled her mother thrashing around in bed, ultimately requiring hospice services and sedation prior to her death. Resident #1's daughter stated she was aware her mother was declining as a result of her disease process but felt she did not have to die in that manner. She stated she would hate for any other resident to suffer similar injuries and for any other family to endure the events that were part of her mother's final days. Resident #1's daughter emphasized concerns regarding the level of supervision provided for her mother and other residents on the Memory Care Unit. She said, Where was the staff when she was going outside or into another resident's room where she did not belong? As a family we are furious about how this ended. Review of resident #1's Certification of Death form issued on [DATE] revealed the Medical Examiner determined resident #1's manner of death was an accident, and her cause of death was complications related to fractures of the left clavicle, left elbow, and left hip. The document indicated the injuries resulted from multiple ground-level falls. On [DATE] at 1:36 PM, in a telephone interview, CNA G verified she was assigned to resident #1 and 16 other residents for the 11:00 PM to 7:00 AM shift on the night the resident fell in her room. She explained resident #1 did not sleep much, and her usual behavior was to be up and down most of the night. CNA G stated resident #1 previously had 1:1 supervision for a while to prevent her from falling and said, She should be on 1:1 all the time. If they did that, there was no way she would have fallen that night. CNA G stated she assisted with picking the resident up off the floor and returning her to bed, then she left the room to continue her morning resident care rounds. On [DATE] at 2:55 PM, in a telephone interview, Licensed Practical Nurse (LPN) C stated resident #1 usually wandered around the memory Care Unit at night and needed frequent monitoring as she was a very high fall risk. He confirmed he was the assigned night shift nurse who discovered resident #1 on the floor in her room on [DATE] at about 4:30 AM. LPN C stated he saw her in bed prior to the fall at about 2:00 AM. He explained it took four staff to transfer resident #1 from the floor back to bed as she could not put any weight on her left leg. LPN C recalled after the fall, resident #1 continued to attempt to get out of bed and staff had to keep an eye on her. He was asked to explain how resident #1 was supervised to ensure she did not attempt to stand and fall again. LPN C said, We took turns to go back and forth and check on her. She kept sitting up on the edge of the bed. LPN C explained he checked on her every 15 minutes but acknowledged he did not assign anyone to sit in the room with resident #1 to ensure her safety although he was aware she was injured. On [DATE] at 4:24 PM, CNA H stated resident #1 was extremely confused and would stand quickly and start walking rapidly, almost running. CNA H explained resident #1 used to fall often, but while on 1:1 supervision she had no falls. CNA H stated she was occasionally assigned to do 1:1 supervision and recalled resident #1 would leave her behind if she did not hold her hand. She stated after 1:1 supervision was discontinued, the resident returned to walking fast around the unit by herself. On [DATE] at 4:32 PM, CNA I stated resident #1 was very confused and redirecting her was not effective as she did not understand or remember instructions. She explained resident #1 walked quickly and was sometimes unsteady. CNA I recalled being assigned to care for the resident on a 1:1 assignment and stated she had to be on constant watch as even with a staff member seated beside her, the resident moved so rapidly she remained at risk for falling. On [DATE] at 4:43 PM, CNA M stated resident #1 required 1:1 supervision to ensure her safety as she was very unsteady on her feet, walked quickly, and had behaviors that put her at risk for falling. She stated she walked with the resident often and either held her hand or stood nearby but was never aware she required use of a gait belt for safety. CNA M explained the resident required constant supervision at all times, even when sleeping. She said, I don't know why they stopped it (1:1 supervision). On [DATE] at 4:59 PM, LPN J stated resident #1 was usually restless and needed constant redirection. She described the resident as gradually becoming more unsteady on her feet and falling more often. LPN J stated resident #1 required 1:1 supervision to prevent falls. She stated she was not sure who made the decision to discontinue continuous monitoring, and explained it was a decision made at the management level, definitely not by staff on the unit. On [DATE] at 5:11 PM, LPN L stated resident #1 did not understand safety issues or dangers of her actions. She explained when resident #1 had a 1:1 sitter she did not wander into other peoples' rooms nor have any falls. LPN L said, She should have stayed on 1:1. On [DATE] at 7:09 PM, LPN D stated she was resident #1's regular night nurse. She explained all staff were aware of how challenging it was to monitor resident #1 as she walked quickly, often tripped on her own feet and wandered all over unit. LPN D said, She would make you a nervous wreck because she continuously got up and down. She rarely sat still. She would hold my waist and walk with me so I could keep track of her. It got to the point where somebody had to be with her all the time. LPN D explained resident #1 was one of the residents on the unit at high risk for falls and even rounding every 15 minutes was not frequent enough for her. She was informed most of resident #1's falls and other incidents were unwitnessed, and she explained CNAs might have been busy with other residents or serving meals. LPN D stated the Memory Care Unit required additional staff to adequately supervise residents at risk for falls. She said, I was relieved when [resident's name] was put on 1:1. It took the pressure off the staff. LPN D recalled on some nights she had to pass medications to other residents while she held resident #1's hand or put her in a wheelchair and brought her into each resident's room. LPN D stated the ideal circumstance and only effective fall prevention intervention was when resident #1 to had 1:1 supervision to keep her safe while she was still ambulatory. LPN D stated even before resident #1 fell on the patio, she was uncomfortable with any resident remaining outside unsupervised. She explained another safety hazard on the unit was the placement of chairs and tables that took up almost all the space in the middle of each side of the unit. LPN D explained the unit's unsteady, confused residents constantly squeezed themselves, their wheelchairs or walkers between the chairs and tables. She described it as not really a good set up. On [DATE] at 12:47 PM, in a telephone interview, the Registered Nurse (RN) Weekend Nursing Supervisor stated resident #1 was almost constantly moving and nurses sometimes put her in a wheelchair and tried to keep her at the nurses' station or had her with them during rounds or medication administration for other residents. She recalled resident #1 had 1:1 supervision due to her high risk for falls and stated she did not know why it was discontinued. The RN Weekend Nursing Supervisor was informed that 1:1 supervision was discontinued suddenly, and she said, Usually we would decrease supervision gradually. She recalled staff notified her of resident#1's fall on the patio and she instructed the assigned CNA to be more mindful of the resident. The RN Weekend Nursing Supervisor acknowledged she did not initiate 1:1 supervision to ensure the resident's safety nor direct staff to implement a specific frequency of monitoring to prevent another fall. On [DATE] at 6:25 PM, during a tour of the Memory Care unit with the UM, she validated the tables and chairs that filled the common area were safety hazards to the unit's residents. The UM explained the placement of the furniture in the middle of the room created challenges for the cognitively impaired residents as they attempted to navigate around the unit. She acknowledged residents did not have clear, unobstructed pathways that allowed them to wander freely. Observation of the B side nurses' station revealed computers were set up so that nurses had their backs to the unit. Observations of the A side nurses' station revealed nurses faced an exercise room and could not see any of the A side dining area while seated at the desk. The UM identified it was challenging for nurses to see, hear or supervise residents on the unit due to the layout. She stated the lighting in the unit was very dim, even at maximum level, and it could present a hazard for visually impaired residents. On [DATE] at 11:36 AM, the Memory Care Unit UM stated resident #1 walked very quickly and over the past few months her gait and balance gradually became more impaired. The UM stated the resident began leaning forward, bumped into things and used the wall or handrail to steady herself. She explained staff were expected to perform safety rounds at the appropriate frequency and noted individual residents required different frequencies for monitoring. The UM acknowledged resident #1 had 1:1 supervision initiated after her second fracture, and when it was discontinued, the plan was to do close monitoring. She said safety rounding should be noted on the resident's nursing care plan and CNA care plan or Kardex. The UM was informed there was no direction on the Kardex regarding safety rounding or a defined frequency of rounding. She stated the regular night nurse, LPN D checked on the resident at least every 15 minutes but she was not sure how often float or agency nurses monitored her. The UM acknowledged on the night resident #1 fell and suffered her third fracture, she was assigned to a float nurse who might not have been aware of the level of supervision necessary for resident #1. On [DATE] at 12:17 PM, Director of Nursing (DON) A explained regular resident rounding was to be done every two hours, and safety rounding should be done more frequently. She acknowledged the facility did not have a defined frequency for safety rounds as it depended on the residents' needs. DON A validated there was no direction provided for staff regarding the level of supervision resident #1 required to ensure her safety and prevent falls. On [DATE] at 12:15 PM, the facility's incident log and resident #1's medical record were reviewed with the UM and DON A. The UM explained after a resident fell , she reviewed all statements and initiated an investigation to determine the root cause. She stated she implemented fall prevention interventions based on her findings and then discussed each incident with the IDT at the next daily meeting to determine if additional approaches should be implemented. The UM reviewed the resident's fall care plan and acknowledged the updated interventions after her recent falls focused on preventing her from going outside unaccompanied and redirecting her away from the B side of the unit. She acknowledged that resident #1 could fall anywhere, and since she kept falling, the interventions were not appropriate or effective. The UM could not explain why all resident #1's falls and incidents between February and [DATE] were unwitnessed by staff although most occurred in common areas, and one occurred during change of shift report when night and day shift staff were present. On [DATE] at 4:54 PM, the UM stated she was not aware of the PT assessment that indicated resident #1 required a gait belt and handheld assistance for ambulation. She provided a copy of the daily CNA Assignment Sheet for the 3:00 PM to 11:00 PM shift on [DATE]. The sheet showed that resident #1 ambulated and wore glasses. The UM confirmed there were no instructions related to fall prevention interventions including use of a gait belt and safety monitoring at specified intervals. On [DATE] at 4:38 PM, and [DATE] at approximately 12:25 PM, DON A reviewed resident #1's care plans and confirmed there were no interventions developed or implemented related to an increased level of supervision or more frequent monitoring after the resident sustained her first fracture on [DATE]. DON A acknowledged resident #1's serious injuries and multiple falls occurred without staff knowledge of the circumstances. DON A stated she could understand how it might seem as if there was inadequate supervision, but she felt one should consider the number of falls and accidents the facility had prevented. DON A stated the facility initiated 1:1 supervision after resident #1's second fracture as they did not want her to fall while her elbow was healing. When asked if the facility considered the possibility of resident #1 falling and fracturing again based on her declining physical and cognitive status and history of falls, DON A said, We did not anticipate her falling after that. DON A acknowledged resident #1 did not fall while she was on 1:1 supervision. She confirmed 1:1 supervision was not gradually tapered before it was discontinued, although she could have chosen to continue this level of monitoring on the 3:00 PM to 11:00 PM shift when resident #1 fell most often. Neither the UM nor DON A recalled discussing alternative fall prevention approaches with the IDT prior to discontinuing 1:1 supervision. On [DATE] at 9:35 AM, Physical Therapist E stated resident #1 exhibited functional changes due to age-related decline and dementia disease progression. He explained that in addition to these issues, use of an arm sling made her even more prone to fall to one side as it impacted use of the affected arm for balance. Physical Therapist E confirmed Physical Therapist F assessed resident #1 and determined she required limited to extensive handheld assistance and a gait belt during ambulation. He concurred these interventions were necessary to[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were assigned to the Memory Care Unit to adequately supervise and monitor the behaviors of physically and cognitively impaired residents to prevent falls with major injuries, for 1 of 5 residents reviewed for falls, of a total sample of 7 residents, (#1). This failure contributed to multiple unwitnessed falls, serious injuries, and the resident's subsequent death. There was likelihood resident #1 suffered excruciating pain as a result of her bone fractures, and she required sedation to control her symptoms of pain and extreme agitation at the end of her life. On [DATE] at approximately 5:00 PM, resident #1, who had known wandering behavior, was left unattended on the outdoor patio of the Memory Care Unit. While repeatedly walking around a planter at the edge of the paved area, she fell hard to the ground and rolled out onto the grassy area adjacent to the patio. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Over the next six weeks, resident #1 suffered three unwitnessed falls, two injuries of unknown origin source, and an incident with a male resident who pulled her backwards across the floor by the collar of her blouse. On [DATE], resident #1 was noted with swelling and discoloration of her left arm. X-rays showed a fracture of the left elbow and a possible fracture of her left wrist. On [DATE] at approximately 4:30 AM, resident #1 was found on the floor in her room after another unwitnessed fall. This incident resulted in a fracture of the left hip. The resident was not a candidate for necessary hip repair surgery, and was referred to hospice for end-of-life services. She died on [DATE], five days after her last fall. There were 29 physically and cognitively impaired residents on the Memory Care Unit and 21 of those residents had behavioral health needs. The facility's failure to ensure sufficient direct care staff were assigned to provide the appropriate level of supervision to mitigate identified fall risk and accomplish care plan goals contributed to resident #1's falls, serious injuries, and subsequent death, and placed all residents at risk for falls resulting in serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F689 and F835 Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's room was located on the A side of the facility's locked Memory Care Unit. The Minimum Data Set (MDS) Quarterly assessment with assessment reference Date (ARD) of [DATE] revealed resident #1 had unclear speech, was rarely or never understood, and rarely or never understood others. Her vision was impaired, and she required glasses. Staff assessment of the resident's mental status indicated she had short-term and long-term memory problems, and severely impaired cognitive skills for daily decision making. During the MDS assessment lookback period, resident #1 exhibited wandering behavior daily. She required extensive assistance with bed mobility, and transfers, but walked independently, without a mobility device. The document revealed during position changes from seated to standing and surface to surface transfers, resident #1 had unsteady balance and was only able to stabilize with staff assistance. The MDS assessment showed her balance was also unsteady during walking, turning around, and moving on and off the toilet, but she was able to stabilize without staff assistance. The document reflected one fall with major injury since the prior assessment. Review of the medical record revealed on [DATE], resident #1 had a care plan initiated for risk for falls due to impulsiveness, cognitive impairment, impaired vision, and over-estimation of self limitations. The care plan indicated the resident walked at a fast pace and had impaired posture which increased her risk for falls. The care plan goal noted resident #1 would not sustain serious injuries from falls. Fall prevention interventions directed staff to anticipate and meet her needs, stop her when she walked too fast, redirect her to slow down, redirect her from the B side of the unit and other residents' rooms, and remind her to wear her glasses. In addition, staff were to remain outside if resident chose to walk outside and encourage her not to walk in the grassy area without assistance. A care plan for progressive cognitive loss, initiated on [DATE], indicated resident #1 needed reminders, cueing and encouragement. The document read, I need staff with me at all times. Resident #1 had a care plan for activities of daily living self-care performance deficit related to dementia, decreased bed mobility and range of motion, and forgetfulness. The care plan was initiated on [DATE], and informed direct care staff that the resident required continuous cueing and prompting to complete tasks independently and assistance to move between surfaces. A care plan for history of aimless wandering initiated on [DATE] indicated resident #1 was cognitively impaired and unaware when she intruded on the personal space of others. The goal was to maintain her safety, and staff were expected to provide supervision, redirection, diversion, cues and reminders as needed. Resident #1's care plans indicated she required frequent to continuous supervision and monitoring by staff to ensure her safety. However, review of the facility's incident log and her medical record revealed from [DATE] to [DATE], the resident had five falls which were all unwitnessed, three injuries of unknown source, and an incident that involved a male resident dragging her on the floor by the collar of her blouse. During this period, the resident suffered a fracture of the left clavicle on [DATE], a fracture of the left elbow and a possible fracture of the left wrist on [DATE], and a fracture of the left hip on [DATE]. On [DATE] at 3:34 PM, in a telephone interview, resident #1's son described the circumstances of incidents and major injuries his mother suffered during her final months in the facility. He became tearful as he expressed frustration that staff were not present at the time of the incidents. Resident #1's son said, I can't understand why every time the facility called to say mom fell , nobody could explain how it happened, because nobody ever saw anything. He explained that after his mother's second fracture, the facility implemented 24-hour supervision to keep her safe. The son stated he was surprised to learn that his mother fell again, and he found out the facility had discontinued the one to one (1:1) supervision on the week prior to her last fall. He said, They told my sister they were short of staff, and they decided to take away the 1:1 nurse. On [DATE] at 4:03 PM, in a telephone interview, resident #1's daughter explained her mother's multiple falls and fractures were listed as her cause of death on her death certificate. She stated the family met with the facility after the first fracture, and they were assured the facility could provide appropriate care for her mother. The daughter stated after the second fracture, the facility informed her they would implement 1:1 supervision to keep her mother safe. She recalled her initial reaction was to question how the facility would be able to accommodate that intervention, but she did not object. The daughter stated the 1:1 supervision was discontinued without the family's knowledge and her mother fell again and sustained a third fracture. She stated the facility never contacted her to discuss possible alternative solutions to increased supervision such as private sitters or family caregivers. Resident #1's daughter emphasized concerns regarding the level of supervision provided for her mother and other residents on the Memory Care Unit. She said, Where was the staff when she was going outside or into another resident's room where she did not belong? As a family we are furious about how this ended. On [DATE] at 1:36 PM, in a telephone interview, Certified Nursing Assistant (CNA) G stated she regularly worked on the Memory Care Unit during 3:00 PM to 11:00 PM and/or 11:00 PM to 7:00 AM shifts. She explained the unit's capacity was 40 residents and at night there were usually two CNAs and one nurse. CNA G recalled on the overnight shift on [DATE] when resident #1 fell in her room, she was one of only two CNAs, and her assignment was 17 residents including resident #1. CNA G stated resident #1 usually wandered the unit for most of the night and it was difficult to watch her and all the other residents too. She explained on the nights the regular nurse, Licensed Practical Nurse (LPN) D worked, she helped CNAs to keep an eye on the residents who wandered, including resident #1. CNA G stated resident #1's behaviors warranted 1:1 supervision as the only way to prevent her falling. She explained two CNAs were not able to properly care for all the residents on the Memory Care Unit and said, And if you and the nurse are busy, the other residents who can walk can be doing anything. On [DATE] at 4:32 PM, CNA I stated resident #1 required constant redirection and supervision as she was very confused, had no safety awareness and walked quickly and unsteadily. CNA I explained although all staff tried to watch and protect resident #1 between caring for their assigned residents, they could not neglect their other residents. She stated on the 3:00 PM to 11:00 PM shift, each CNA assignment was usually up to 12 residents. CNA I recalled even when on 1:1 supervision, resident #1 remained at risk for falling so the assigned CNA had to be extremely close to her, often holding her hand or resting an arm on the resident's leg to slow her movements. CNA I pointed to residents seated in the unit's dining area and said, We can't leave them in a room. They are at risk for falls, and they have to be out here together so I can watch a few at the same time. We try to take turns to watch them in the common area. It doesn't work for most part because you can't be in more than one place. On [DATE] at 5:11 PM, LPN L stated resident #1 did not understand safety issues or dangers of her actions. She explained when resident #1 had a 1:1 sitter she did not wander into other peoples' rooms nor have any falls. She stated there were several residents on the Memory Care Unit who wandered all night, and it was impossible for one CNA to monitor up to 20 residents who were awake and/or wandering, as well as do rounds to check on and care for the residents who remained in their rooms. LPN L said, It can be very hard to watch these residents. I used to work at night, but I stopped because of what it's like here. I could not sit at the nurses' station. She explained she was not able to visualize the residents on one side of the unit, much less residents on the other side and spent most of the shift standing or walking. LPN L also noted there were residents on the unit who required two to three staff to provide care and at those times there was no staff member available to monitor other residents. On [DATE] at 7:09 PM, LPN D stated she was resident #1's regular night nurse. She explained all staff were aware of how challenging it was to monitor resident #1 as she walked quickly, often tripped on her own feet and wandered all over the unit. LPN D said, She would make you a nervous wreck because she continuously got up and down. She rarely sat still. She would hold my waist and walk with me so I could keep track of her. It got to the point where somebody had to be with her all the time. LPN D explained resident #1 was one of the residents on the unit at high risk for falling and even rounding every 15 minutes was not frequent enough for her. She said, I was relieved when [resident's name] was put on 1:1. It took the pressure off the staff. LPN D recalled on some nights she had to pass medications to other residents while she held resident #1's hand or put her in a wheelchair and brought her into each resident's room. LPN D stated the ideal circumstance and only effective fall prevention intervention would be for resident #1 to have 1:1 supervision to keep her safe while she was still ambulatory. LPN D explained the Memory Care Unit required additional staff to adequately supervise residents at risk for falls. She explained decreasing staffing was not fair to staff or residents, even if the census was slightly lower, because residents' behaviors remained the same. LPN D stated ideally staff should monitor the residents who were at high risk for falls every 15 minutes. She confirmed the Memory Care Unit was typically staffed with two CNAs to care for up to 40 resident and until very recently, one nurse for the entire unit. She said, We need at least three CNAs every night, and that is a minimum and does not count for any residents who had behavior issues or needed more attention for whatever reason. LPN D stated the layout of the unit presented challenges related to visualizing residents in different areas, so having sufficient staff was essential to ensure all residents were supervised. She stated although the 11:00 PM to 7:00 AM shift presented its own challenges, she had significant concerns about the staffing on the 3:00 PM to 11:00 PM shift. LPN D said, I sympathize because there is less staff, less management, less therapists, and overall fewer people around than [on the] ,d+[DATE] shift. It is unfortunate as a lot of the residents start to have behaviors and then families start to visit after work. On [DATE] at 12:47 PM, in a telephone interview, the Registered Nurse (RN) Weekend Nursing Supervisor confirmed she worked on the Sunday afternoon that resident #1 fell and fractured her clavicle on the outdoor patio. She stated she was not aware the resident was outside alone. The RN Weekend Nursing Supervisor said, I don't know if it was one of the days I was on a [medication] cart. At times there is a staffing problem on the weekends. I am sometimes required to supervise and work at the same time. She described resident #1 as almost constantly moving and only participated in activities or sat with staff for brief intervals. She recalled many shifts when she had a nursing assignment and took resident #1 into other residents' rooms during medication administration in order to watch her closely. She said, You have to do the best possible, but it's not ideal to pass medications that way. The RN Weekend Nursing Supervisor stated resident #1 eventually required 1:1 supervision due to her high risk for falling, but it was discontinued, and she was not told the reason. She was informed on the night resident #1 fell in her room, her assigned CNA had a total of 17 assigned residents. The RN Weekend Nursing Supervisor was not able to explain how one CNA could care for and monitor 17 Memory Care Unit residents. When asked how many CNAs she would recommend for each shift, the RN Weekend Nursing Supervisor stated five to six CNAs for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts would be ideal. On [DATE] at 3:48 PM, Director of Nursing (DON) A validated each resident on the Memory Care Unit should have individualized fall prevention interventions. She provided examples such as increased frequency of rounding, increased monitoring, and engagement in activities. DON A acknowledged resident #1's falls and injuries of unknown origin were unwitnessed and explained staff did not see any of the incidents as she was fast, impulsive, and unpredictable. When asked if there was sufficient staff on the Memory care Unit to provide adequate supervision to meet the resident's needs, DON A said, There was no staffing issue as far as I could tell. DON A confirmed on the night shift when resident #1 fell in her room and suffered a left hip fracture, the unit was staffed with two CNAs. She validated each CNA was assigned to 17 residents and explained staffing was sufficient as nurses could have assisted with monitoring residents in their downtime and CNAs did not have to continuously interact with residents at night. She stated her expectation was for staff to round at least every two hours and if necessary, one nurse could have assumed care of the entire unit and the other nurse could have assumed responsibility for any residents who required more frequent monitoring. On [DATE] at 10:21 AM, the Activity Assistant stated the Memory Care Unit had a program seven days weekly from 8:00 AM to 4:30 PM specifically for its cognitively impaired residents. She explained either one or two staff from the Activity Department assisted with monitoring residents like resident #1 who were high risk for falls during those hours by engaging them in variety of activities. The Activity Assistant confirmed there were no structured activities after 4:30 PM, and she left building blocks on the table and puzzle books for a few of the higher functioning residents. On [DATE] at 10:02 AM, DON B denied prior knowledge of staffing concerns and described staffing on the Memory Care Unit as typically generous. She said, We believe we staff more than required for the dementia unit. DON B was asked to review the staffing calculation forms and staff schedules. She acknowledged for [DATE] and [DATE], the night shift on the Memory Care Unit was often staffed with two CNAs for a census that ranged from 29 to 40 residents, a ratio between 1:14 and 1:20. In addition, DON B verified there were fewer CNAs assigned on the 3:00 PM to 11:00 PM shift than the 7:00 AM to 3:00 PM shift on almost every day. DON B offered no explanation regarding how one CNA could adequately monitor 14 to 20 confused residents who had unpredictable habits, behavioral symptoms including combativeness and wandering, and low levels of safety awareness. She did not respond when asked how the assigned CNA could have cared for 16 residents in addition to supervising resident #1 frequently on the night of her last fall in the facility. Review of the current Florida Calculating State Minimum Nursing Staff for Long Term Care Facilities form for the Memory Care Unit for the period [DATE] to [DATE] revealed there were two CNAs on 10 of 14 night shifts for a daily census that ranged from 29 to 34 residents. The document showed there were fewer CNAs on the 3:00 PM to 11:00 PM shift than the 7:00 PM to 3:00 PM shift on 12 of 14 days. On [DATE] at 10:33 AM, the Memory Care Unit manager (UM) confirmed the design of the unit seemed like two separate units, so more staff were needed to supervise the residents. The UM explained during the construction stage for the building, she informed the facility's administration of the potential challenges related to the layout of the unit. She recalled, I said we're going to need more staff. We're never going to be able to see the people. The UM acknowledged resident #1 required a very high level of supervision to ensure her safety, and nurses who conducted medication administration while monitoring the resident presented another safety concern. The UM explained the unit used to be staffed with only one nurse until very recently and it was difficult for one nurse to monitor even one side, and impossible to monitor both sides of the unit. The UM validated the unit was sometimes insufficiently staffed, especially during the evening and night shifts. She stated she often requested additional staff, especially on the 3:00 PM to 11:00 PM shift, without success. The UM explained residents on the unit started sundowning from about 3:00 PM and their behaviors gradually escalated, worsened around dinnertime, and then usually settled down by about 8:00 PM. She stated it was unfortunate the Memory Care Unit usually had less staff during the hours residents needed even more assistance and monitoring. The term sundowning refers to confusion that occurs from late afternoon into the night. Sundowning can cause different behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering. These symptoms may affect patients with different types of dementia (retrieved on [DATE] from www.mayoclinic.org). On [DATE] at 11:38 AM, a meeting was held with DONs A and B, and the Administrator. DON A stated she was aware the number of staff assigned to the Memory Care Unit was lower on the evening shift than the day shift. She did not respond when asked if the facility considered the staffing needs of this resident population related to expected sundowning behaviors. DON A confirmed resident #1's falls and other injuries were unwitnessed, and she could not explain where all staff were at the times these incidents occurred. DON B was asked to clarify her description of generous staffing on the unit. She explained the average number of direct care staffing hours was generous when viewed over a 24-hour period as it reflected the generous number of staff who worked during the day shift. The Administrator stated he was not aware of any concerns related to insufficient staff on the Memory Care Unit to meet the residents' needs. He explained staffing was adequate as the facility exceeded the State-required minimum number of direct patient care hours every day. He did not respond when reminded of Federal regulations that pertained to provision of sufficient staff to ensure residents of the specialized Memory Care Units received all the necessary, individualized care and services, including appropriate supervision by staff, to guarantee their safety and optimal level of well-being. Review of the Facility Assessment revised in [DATE] revealed the facility provided services including memory care in a dedicated unit. The document indicated the facility could care for residents with common diseases, conditions, and physical and cognitive disabilities, and meet the needs of residents with Alzheimer's Disease, and non-Alzheimer's dementia. Other general resident care needs were assistance with mobility and prevention of falls or falls with injury. The document included a Staffing Plan that indicated the facility would provide sufficient staff to meet residents' needs according to their assessments and plans of care. The assessment revealed the facility would adjust staffing schedules as needed and daily assignments would reflect residents' needs. Review of the job description for Nursing Director or DON, revised on [DATE], revealed the DON organizes, directs, and supervises the day-to-day activities of the facility's nursing department. The DON was expected to facilitate resident-centered care and ensure plans of care reflected individualized needs, goals, and approaches. The DON's essential functions included Ensures a sufficient number of nursing staff is assigned daily to meet the total nursing needs of the residents. Review of the job description for Administrator revised on [DATE], revealed he was responsible for the day-to-day functions of the facility including ensuring an adequate number of staff were assigned at all times to meet residents' needs. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On [DATE], the facility completed a whole house audit of fall risk scores and fall care plans. The audits identified 1 of 30 residents required fall risk score revision, and 21 of 30 residents' care plans required updates regarding behavioral needs based on discussion with the UM and CNAs. * On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to develop a corrective action plan including necessary immediate plans. * On [DATE], the staffing schedule and patterns were reviewed to ensure sufficient direct care staff were assigned to provide adequate supervision for residents. An escalation process was developed to ensure ongoing staffing needs are met. Immediate actions included assignment of a designated CNA to Safety Rounding duties only every shift, dedicated activity staff and a CNA will supervise all outdoor activity, and activity program hours were extended to 8:00 AM - 8:00 PM daily to allow for increased monitoring during sundowning timeframe. * On [DATE], education was initiated on Safety Rounding and Outdoor Supervision and is ongoing. Safety rounds sheet is to be used for every 15-minute documentation regarding residents' locations, status and activities until individual patterns are identified. Information will be used to develop the appropriate, individualized frequency of supervision. 100% of all staff who worked on [DATE] and [DATE] received education. Ongoing until 100% of staff complete training. * On [DATE], the UM received education regarding reporting any new or increased staffing needs and other concerns that require adjustment to staffing. * On [DATE], an ad hoc QAPI meeting was held to review the fall policy, procedure, and interventions. Discussions included development, education, and implementation of the plan of correction. Attendees by both DONs, Medical Records staff, the Administrator, Social Worker, the Advanced Practice Registered Nurse, the Unit Memory, and the Medical Director. * On [DATE], staffing schedules for four days ([DATE] to [DATE]) were updated to reflect assignment of a safety rounding staff member every shift. * On [DATE], the facility implemented a reference sheet for the Memory Care Unit to ensure agency and float staff receive unit specific safety education on topics including secured exits, safety rounding, reading the Kardex, walking rounds, shift huddle and activities The document will be kept in the supervisor's book and binders at nurses' stations. * On [DATE], the staff scheduler was educated via telephone on ensuring the minimum staff requirements for the Memory Care Unit are met, to include safety rounding CNAs, designated activity staff, and extended activity hours. Review of in-service attendance sheets validated education was completed according to the facility's plan. On [DATE], interviews conducted with 9 staff including 1 RN, 2 LPNs, 5 CNAs, and 1 Unit Secretary revealed staff participated in required in-services and were knowledgeable of the facility's fall prevention policy and procedure. Staff verbalized the importance of providing the appropriate levels of supervision for cognitively and physically impaired residents. They verified any increase or change in behavior should be reported to the UM, supervisor, and/or the DON. All staff were aware doors to the patio should remain locked until a staff member was available to accompany and remain outside with residents. CNAs were observed as they conducted safety rounding and all staff interviewed were able to explain the purpose and process of safety rounding. The sample was expanded to include 4 additional residents at risk for falls. Observations, interviews, and record reviews revealed residents #2, #3, #12, and #13 had accurate fall risk evaluations and care plan interventions were in place.

Based on observation, interview and record review, the facility failed to effectively utilize its resources to develop appropriate, individualized fall prevention interventions; failed to schedule sufficient staff to provide adequate supervision and monitoring; and failed to maintain a safe environment in the Memory Care Unit for 1 of 5 residents reviewed for falls, of a total sample of 7 residents, (#1). These failures contributed to multiple unwitnessed falls, serious injuries, and the resident's subsequent death. There was likelihood resident #1 suffered excruciating pain as a result of her bone fractures, and she required sedation to control her symptoms of pain and extreme agitation at the end of her life. On [DATE] at approximately 5:00 PM, resident #1 was left unattended on the outdoor patio of the Memory Care Unit. While repeatedly walking around a planter at the edge of the paved area, she fell hard to the ground and rolled out onto the grassy area adjacent to the patio. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Over the next six weeks, resident #1 suffered three unwitnessed falls, two injuries of unknown source, and an incident with a male resident who pulled her backwards across the floor by the collar of her blouse. On [DATE], resident #1 was noted with swelling and discoloration of her left arm. X-rays showed a fracture of the left elbow and a possible fracture of her left wrist. On [DATE] at approximately 4:30 AM, resident #1 was found on the floor in her room after another unwitnessed fall. This incident resulted in a fracture of the left hip. The resident was not a candidate for necessary hip repair surgery, and was referred to hospice for end-of-life services. She died on [DATE], five days after her last fall. There were 29 physically and cognitively impaired residents on the Memory Care Unit. The failure of the facility's administration to develop and/or implement systems and processes to identify and provide the appropriate level of supervision and/or frequency of monitoring contributed to resident #1's falls, serious injuries, and subsequent death, and placed all residents who were at risk for falls in danger of suffering serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F689 and F741. Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's room was located on the A side of the facility's locked Memory Care Unit. Resident #1's medical record included care plans for falls, aimless wandering, activities of daily living self-care performance deficit, and progressive cognitive loss. The care plans showed she required frequent to continuous supervision and monitoring by staff to ensure her safety. Review of the facility's incident log and the resident's medical record revealed from [DATE] to [DATE], she had five falls which were all unwitnessed, three injuries of unknown origin, and an incident that involved a male resident dragging her on the floor by the collar of her blouse. During this period, the resident suffered a fracture of the left clavicle on [DATE], a fracture of the left elbow and a possible fracture of the left wrist on [DATE], and a fracture of the left hip on [DATE]. On [DATE] at 11:36 AM, the Memory Care Unit Manager (UM) confirmed resident #1 was one of approximately five residents on the unit who she classified as high-risk, frequent fallers. She explained fall prevention interventions for these residents included a daytime activities program, close monitoring, and safety rounding. The UM was informed safety rounding, and the frequency of monitoring were not noted on resident #1's plan of care. She validated nursing staff, especially float or agency staff, would not be aware of this fall prevention intervention or the required frequency. On [DATE] at 12:17 PM, Director of Nursing (DON) A stated her expectation was CNAs would conduct regular rounds to check on their assigned residents at least every 2 hours. She explained safety rounding should be done with increased frequency, depending on each resident's needs. DON A acknowledged the facility did not develop or implement safety rounds with a defined frequency to prevent falls for resident #1. On [DATE] at 4:38 PM, DON A confirmed she was the facility's DON at the time of resident's first and second fractures. She recalled resident #1's daughter sent a letter to the facility and hospital administration after the first fracture regarding issues with her mother's care and safety concerns related to recent falls and incidents. DON A recalled a team composed of facility representatives and hospital administration met with the resident's family. She could not recall if there was discussion during or after the meeting regarding increased supervision for resident #1. She acknowledged one to one (1:1) supervision was initiated about four weeks after the meeting and three additional, unwitnessed falls, when the resident's second fracture was discovered. DON A acknowledged the facility discontinued 1:1 supervision without tapering to identify risks and patterns. On [DATE] at 10:33 AM, the UM recalled during the construction phase of the facility, she informed administration including the Administrator and the Medical Director that the design and layout of the Memory Care Unit would necessitate additional staff to adequately monitor residents and ensure their safety. She confirmed issues regarding the unit's layout and the need for more staff were discussed more than once in daily interdisciplinary (IDT) team meetings. The UM stated she was aware nurses had to take resident #1 along with them as they did medication administration rounds to supervise her. She said, I have kept telling them I need more staff. If up to me, I would probably have put her on 1:1 earlier, but I did not make the decision to put her on or take her off (1:1 supervision). On [DATE] at 10:02 AM, DON B stated within the past two weeks she was made aware of the difficulties staff had with supervising residents due to the design of the unit. She said, I am now aware that staffing is a concern down there. On [DATE] at 11:38 AM, the facility's Administrator and DONs A and B provided an agenda and attendance sheet for a Quality Assurance and Performance Improvement (QAPI) committee meeting titled, Fall Meeting [DATE] - Ad [NAME] QAPI. The agenda indicated the facility planned to develop a Performance Improvement Plan in the future, date undetermined. DON A explained the purpose of the meeting was to review fall trends and prepare for the facility's upcoming annual recertification and relicensure surveys. Neither DON A, DON B, nor the Administrator verbalized the ad hoc meeting was associated with resident #1's multiple falls with major injuries. DON A stated the team identified the placement of tables in the center of the unit as a hazard and discussed moving them closer to the walls. In addition, she stated they discussed the difficulties nurses had in visualizing residents, but were not aware of staff concerns regarding insufficient staff. DON A did not respond when asked if administration or the QAPI committee identified the evening shift staffing needs of this population as an area of concern or discovered that the IDT had not included safety rounding and specified the frequency of monitoring needed for resident #1 or other residents during IDT review of falls. She validated the IDT was not aware Therapy recommendations were never implemented to ensure resident #1's safety during ambulation as the required departmental communication form was not used. The Administrator, DON A and DON B were informed interviews with frontline nursing staff revealed all the above mentioned issues were not recent, and had been reported to administration. They were asked if administration involved frontline staff in the process of determining how the facility's resources would be allotted and if current processes needed to be altered, DON A said, We have not included front line staff in discussion yet. Despite four requests from [DATE] to [DATE], the facility was unable to provide an original, legible QAPI meeting attendance sheet for review. The Administrator and the DONs could not explain why information regarding the ad hoc QAPI meeting was not presented to the survey team on entrance on [DATE] when the fall investigation started. They did not respond when asked why all the issues noted on the agenda that were identified and discussed on ,d+[DATE], were not implemented immediately to prevent further falls and major injuries. On [DATE] at approximately 11:45 AM, DON B validated administration had not implemented any interventions in the Memory Care Unit during the 20-day period since the date noted on the QAPI meeting agenda. She explained nothing had been done related to rearranging furniture, setting up workstations for nurses to increase their ability to see residents, increasing the number of assigned CNAs, extending the Activity department's program hours, increasing lighting levels in the unit, and ensuring residents were supervised and monitored with defined, individualized frequencies. Review of the job description for the Nursing Director or DON, revised [DATE], revealed the DON's essential functions included organizing and directing the nursing department and developing methods to ensure inter-departmental collaboration to promote resident-centered care. The DON was expected to serve as a resource person who could interpret policies, and utilize resources in a way that facilitated optimal medical and nursing care. The job description for the Administrator revised [DATE], revealed he was responsible for directing the day-to-day functions of the facility. Essential functions included planning, developing, implementing and evaluating the facility's programs and activities. The Administrator was expected to maintain an effective QAPI program .that focuses on indicators of the outcomes of care and quality of life. The job description indicated the Administrator would also ensure every resident received the necessary care and services to attain the highest practicable level of well-being according to individual care plans. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to develop a corrective action plan including necessary immediate plans. * On [DATE], the staffing schedule and patterns were reviewed to ensure sufficient direct care staff were assigned to provide adequate supervision for residents. An escalation process was developed to ensure ongoing staffing needs are met. Immediate actions included assignment of a designated CNA to Safety Rounding duties only every shift, dedicated activity staff and a CNA will supervise all outdoor activity, and activity program hours were extended to 8:00 AM - 8:00 PM daily to allow for increased monitoring during sundowning timeframe. Staffing needs will be discussed daily to adequately met staffing needs and ensure appropriate staffing ratios. * On [DATE], the facility completed a whole house audit of fall care plans. Care plan audits identified 21 residents' care plans required updates regarding behavioral needs. Appropriate interventions were implemented including safety monitoring. * On [DATE], the Dementia Education and Resource Coordinator was contacted and is scheduled to meet with the facility's administrative team and UM in weekly Risk meeting to discuss residents' behavioral issues. * On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to develop a corrective action plan including necessary immediate plans. * On [DATE], the facility implemented at least weekly IDT review of residents with repeat falls to determine root causes and identify appropriate level of supervision to mitigate safety concerns. The Therapy Director or designee will discuss any new recommendations that need to be communicated to direct care staff. * On [DATE], the UM received education regarding reporting any new or increased staffing needs and requesting an IDT meeting for concerns related to fall risks, behaviors, and safety concerns. * On [DATE], the facility implemented a revised process to involve frontline staff attendance at monthly QAPI meetings to ensure unit-specific concerns are brought to the attention of administration. * On [DATE], the furniture in the Memory Care Unit was rearranged and the lighting was updated to improve environmental safety. A nurse's documentation desk was placed at the center of each side of the unit. * On [DATE], the staff scheduler was educated via telephone on ensuring the minimum staff requirements for the Memory Care Unit are met, to include safety rounding CNAs, designated activity staff, and extended activity hours * On [DATE], education was initiated for licensed nurse on implementation of .appropriate fall prevention intervention(s) after every fall. Care plan and Kardex to be updated. Nurses must change assignments if necessary to accommodate residents' behavior and safety needs and report behavior changes to UM or DON. Education is ongoing. * On [DATE], all above education was completed by the facility's administrative staff. * On [DATE], 90% of Therapy department staff received education regarding communication with the Nursing department by utilizing the designated form. To cite specific needs or precautions identified. All staff will be educated prior to working next scheduled shift. Review of in-service attendance sheets validated education was completed according to the facility's plan. On [DATE], interviews conducted with 9 staff including 1 RN, 2 LPNs, 5 CNAs, and 1 Unit Secretary revealed staff participated in required in-services and were knowledgeable of the facility's fall prevention policy and procedure. Staff verbalized the importance of providing the appropriate levels of supervision for cognitively and physically impaired residents. They verified any increase or change in behavior should be reported to the UM, supervisor, and/or the DON. All staff were aware doors to the patio should remain locked until a staff member was available to accompany and remain outside with residents. CNAs were observed as they conducted safety rounding and all staff interviewed were able to explain the purpose and process of safety rounding. The sample was expanded to include 4 additional residents at risk for falls. Observations, interviews, and record reviews revealed residents #2, #3, #12, and #13 had accurate fall risk evaluations and care plan interventions were in place.

Based on interview and record review, the facility failed to implement the Abuse Prohibition Policy and Procedure related to reporting of abuse for 6 of 6 residents reviewed for abuse, (#8, #16, #361, #41, #20, #43) and failed to initiate interventions to protect 40 of 40 vulnerable residents in the Memory Care Unit. Findings: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed resident #16 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated she was unable to complete the interview. The assessment revealed her cognitive skills for daily decision making were severely impaired. Review of resident #16's medical record revealed a care plan initiated on 3/27/20 for potential physically aggressive behavior. The care plan focus described her as showing impulsive, combative behavior toward others, having poor impulse control, and hitting others for no reason. On 6/08/21 at 11:10 AM, Activity Assistant K stated resident #16 did not usually participate in group activities. He explained she preferred to do 1 on 1 activities with her. Sometimes I have her sit next to me while I am doing a class because she has sporadic behaviors which are not provoked but more spontaneous. She likes to wander around and as she is walking, she will randomly stop and bop somebody. Activity Assistant K stated during the previous week resident #16 hit two residents in one day. He stated staff were to report these types of incidents to the nurse as soon as they happened. On 6/08/21 at 10:25 AM, Certified Nursing Assistant (CNA) J said, [Resident #16] does have a habit of tapping on people. I have not witnessed it but I have heard about it. She likes a certain spot at the table and she will tell the person to move and tap her. We try to keep the residents away from her spot. She has never hit me, always hugs me but other staff have said she has hit them. We have to keep a close eye on her. On 6/08/21 at 10:46 AM, Licensed Practical Nurse (LPN) C said, [Resident #16] has unpredictable behavior. If we see her getting close to another resident we have been instructed to distract her and move her away. She has hit the cat when he is in the room. On 6/08/21 at 11:00 AM, CNA O stated resident #16 should not be allowed to get close to the residents because she might hit them. He recalled other staff told him she usually approached people and hit them for no reason. Review of resident #16's nursing progress notes from 3/05/20 to 5/27/21 revealed 18 notes that described the resident exhibiting aggressive behavior. A note dated 3/05/20 at 6:15 PM read, Resident was observed making contact with another resident's right cheek with an open palm. A note dated 6/15/20 at 3:40 PM read, Resident observed making hand contact with another resident's face. On 6/27/20 at 4:00 PM a note read, Resident observed making hand contact with a male resident's face. A note dated 12/03/20 at 2:30 PM read On 12/02 resident again displayed aggressive behaviors towards others and on 12/3 resident was observed by writer walking up to neighborhood cat and kicking the cat. A note dated 5/27/21 at 10:52 AM read, During activity resident was roaming around and slapped the face of another resident and exited quickly to her room. On 6/10/21 at 2:08 PM, the Risk Manager (RM) confirmed the facility was not able to identify all the residents involved in altercations with resident #16 and who were affected by her aggressive behaviors since March 2020. None of the notes identified individual residents or staff who were affected by the aggressive behavior. On 6/07/21 at 3:57 PM, the Director of Nursing (DON) was informed that on 5/27/21 resident #16 slapped resident #8 in the head. The DON stated the facility typically did not report incidents between residents that occurred on the Memory Care Unit. She explained the RM did not consider these incidents to be reportable to the State Survey Agency as residents on the Memory Care Unit were cognitively impaired and therefore did not have the intent to abuse each other. On 6/07/21 at 4:11 PM, the RM stated resident #16 had behavior issues. She confirmed the incident had an episode when resident #16 walked by resident #8 and smacked her in the head for no reason and kept on walking. The RM said, when I look at the definition in the policy, I do not believe this was a willful act by [resident #16]. She could not even recollect that she did it. She had history of hitting residents in the past. If the resident was higher functioning or the resident was smacked willfully, we would have reported the incident. In this case, both residents were severely impaired cognitively. On 6/10/21 at 8:19 AM, LPN L said, I wish I could figure out when or why she strikes out at other residents. It is hard to say because she just randomly walks past someone and flips her hand out at them. She is not provoked into doing it and she does not appear to single any particular person out to do it. You have to stay on guard with her because many times she will walk up to you and give you a big hug and other times she slaps. She has slapped me. It is hard to say what she is going to do. She is very random. On 6/10/21 at 8:35 AM, the Advanced Practice Registered Nurse (APRN) M said, I do not know what sets [resident #16] off, she is very unpredictable The staff have been better at keeping a close eye on her but they cannot be with her all the time. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS significant change assessment dated [DATE] revealed she had a BIMS score of 3 which indicated her cognitive skills were severely impaired. Review of resident #8's medical record revealed a progress note dated 6/07/21 at 3:24 PM, that read, slapped in head by another resident at breakfast on 5/27/21. 3. Resident # 361 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident # 41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed a progress note dated 3/21/21 at 7:54 PM, that read, Resident stated that he was hit in the head by another Memory Care resident. 5. Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #20 that resulted in resident #20 suffering a bruise on her arm. The RM explained resident #43 was confused and thought resident #20 was in her room. 6. Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of her medical record revealed a progress note dated 5/08/21 at 6:45 AM, that read, During AM medication administration resident [#20] informed this writer that a woman in a wheelchair came into my room last night and grabbed my arm and said get out of my house. On 6/10/21 at 2:08 PM, the RM stated the resident-to-resident altercations were not reported to the State Survey Agency because none of the incidents resulted in any physical harm to the residents. The RM explained she felt the incidents were not willful acts and said, because they really do not know what they are doing. The RM acknowledged these types of incidents would have been reported if they had occurred between residents who were not cognitively impaired. Review of the Resident to Resident Altercations policy and procedure (undated) revealed the facility would, Report incidents, findings and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. The policy included the direction to Make any necessary changes in the care plan approaches to any or all of the involved individuals. Review of the Abuse Prevention Program Policy Statement (undated) revealed the intent to protect residents from abuse by anyone including staff and other residents. The document indicated the facility would Identify and assess all possible incidents of abuse [and] investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on record review and interview, the facility failed to complete Minimum Data Set (MDS) comprehensive admission assessments for 13 residents, (#263, 264, 265, 260, 113, 269, 270, 271, 275, 276, 4, 277, 28) and discharge assessments for 10 residents, (#7, 266, 267, 268, 272, 273, 274, 265, 18, 271) within the required timeframe for 21 residents reviewed for assessments of a total sample of 50 residents. Findings: Review of the medical records revealed the following 13 residents were admitted on the following dates and did not have admission comprehensive assessment completed within the required 14-day period, residents #263, #264, and #265 were admitted on [DATE], resident #260 was admitted on [DATE], residents #113 and #269 were admitted on [DATE], residents #270 and #271 were admitted on [DATE], resident #275 was admitted on [DATE], residents #276, #4, and #277 were admitted on [DATE] and resident #28 was admitted on [DATE]. The following 10 residents did not have their discharge MDS assessment completed as required, resident #7 who was discharged from the facility on 5/13/21, resident #266 discharged on [DATE], residents #267 and #268 discharged on [DATE], resident #272 discharged on [DATE], resident #273 discharged on [DATE], resident #274 discharged on [DATE], resident #265 discharge on 5/24/21, resident #18 discharged on [DATE] and resident #271 was discharged on [DATE]. On 6/9/21 at 2:51 PM, the Director of Nursing acknowledged the facility was not timely in completing residents' MDS assessments and said, we know that we are late and are doing the best we can. On 6/10/21 at 11:29 AM, the MDS Manager verified the list of 13 residents who did not have their admission comprehensive assessment completed within 14 days of admission, and 10 residents who did not have their discharge assessment completed in the 14-day requirement. This was a total of 21 residents who did not have either admission and/or discharge assessments completed timely. Residents #265 and #271 did not have either assessment completed. There was a total of 23 assessments out of compliance. Section 5.2 of the RAI Version 3.0 Manual indicated that for all non-Admission Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment System (PPS) assessment the MDS completion date (Z0500B) must be no later than 14 days after the Assessment Reference Date (A2300). For the admission assessment, the MDS completion date (Z0500B) must be no later than 13 days after the Entry Date (A1600)

Based on interview and record review, the facility failed to obtain admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #110 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/07/21 at 1:01 PM, resident's #110's daughter stated on the previous morning, she visited the facility and asked the assigned nurse about her father's blood sugar levels. The daughter stated she was surprised to learn from the nurse there were no orders to check her father's blood sugar or administer insulin. The daughter stated the nurse checked his blood sugar in response to her request and informed her the reading was greater than 500 milligrams (mg)/deciliter (dL), unreadable by the machine. Resident #110's daughter stated she discovered although her father's blood sugars had not been checked and he did not receive insulin for his first 3 days in the facility despite being insulin dependent diabetic. The daughter said, He was sleepier and did not look like himself. He is usually alert and talkative. She recalled during the 3-day period she informed nurses that her father did not seem normal, and she was told his symptoms could be side effects of the anesthesia he received in surgery approximately 2 weeks before. A normal blood sugar level for adults with diabetes is between 80-130 mg/dL (retrieved from www.cdc.gov on 6/15/21). Review of the hospital Discharge Summary dated 6/02/21, revealed resident #110 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the New Admission Report Sheet completed by the nurse who received telephone report from the hospital nurse on 6/03/21 included resident #110 was on insulin & sliding scale. Review of the facility admission evaluation form dated 6/03/21 indicated resident #110 received insulin. His physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed no documentation to show why resident #110 required this medication. There were no orders to monitor blood sugar or administer insulin regularly until 6/06/21, after his family notified the facility he was diabetic. On 6/08/21 at 4:37 PM, Licensed Practical Nurse (LPN) I stated it was important to review all hospital paperwork for newly admitted residents including the medication list and the History and Physical (H&P) because the information was necessary to obtain admitting orders from the attending physician. LPN I explained the medication list should be verified with the resident and/or family during the admission process. LPN I confirmed residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/09/21 at 11:32 AM, LPN G explained that prior to admission, nurses received verbal report on new residents from the hospital. She added that managers also had electronic access to hospital records. In addition, LPN G explained a packet of documents was supposed to arrive with the new resident. She stated during admission assessments, she reviewed the medication list with the resident or called the family if the resident was cognitively impaired. LPN G stated the admission process also involved notifying the physician of the new resident's arrival and reviewing medication list and assessment findings. She recalled she worked on the previous Sunday, 6/06/21, when resident #110's nurse could not find physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN G stated she went to the resident's room to assist the assigned nurse and his family told her prior to his hospital stay he required long-acting insulin at night and short-acting insulin if necessary. LPN G said, He was confused and disoriented, and I could see why. LPN G stated she attempted to obtain his blood sugar level but was unsuccessful as the reading was too high to register on the glucometer. LPN G said she contacted the physician and received orders to administer insulin and initiate scheduled blood sugar monitoring. A nursing progress note written by LPN G on 6/06/21 at 11:00 AM read, Resident with increased confusion, decreased alertness, [blood glucose] showed too high to read. On 6/09/21 at 4:18 PM, the Rehab Unit Manager (UM) explained the admission nurse was expected to review the hospital transfer form, History and Physical (H&P) form, and the medication list prior to contacting the on-call physician who would verify the orders. The UM stated she was aware resident #110 did not arrive with a complete medication list from the hospital. She said she contacted the Director of Nursing (DON), who obtained a Discharge Summary from the hospital electronic medical record. The UM said that new admissions process included a chart review by the clinical team. On 6/10/21 at 2:27 PM, Advanced Practice Registered Nurse (APRN) P stated she first assessed resident #110 on 6/04/21, the day after admission. She said she could not recall the existing medication orders or medical history from the chart. The APRN P said, I would think that if a patient is diabetic, the hospital orders for insulin carry over to the facility. She was informed the hospital Discharge Summary indicated resident #110 had uncontrolled diabetes and the H&P included laboratory results that supported this diagnosis. The APRN P said, I probably missed it, I could not remember. She acknowledged a patient with untreated uncontrolled diabetes could suffer complications including re-hospitalization . Review of APRN P's progress note dated 6/04/21 showed [MEDICATION(S)] insulin listed as one of his medications and Type 2 diabetes listed under his previous medical history. The note showed APRN did not give new orders for insulin for resident #110. On 6/10/21 at 2:43 PM, the Director of Nursing (DON) explained the admission process occurred over a 24-hour period and included medication review and assessments. The DON confirmed that on the day resident #110 was admitted she was informed the facility did not receive discharge orders from the hospital. She stated she retrieved the discharge summary and emailed it to the nursing supervisor. The DON was informed the Discharge Summary did not contain a complete list of resident's #110 medications. The DON explained the discharge summary was the only document used by nurses for initial medication reconciliation. The DON explained all new admissions were discussed in daily clinical meeting, but the team did not review hospital discharge paperwork as part of the process. The DON could not explain why the admission nurse gave a one-time dose of [MEDICATION(S)] 2 units with no documentation of blood sugar level. The facility policy & procedure titled, Admission Assessment and Follow Up: Role of the Nurse (undated) read, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan . The document indicated nurses would conduct an admission assessment including a summary of the resident's recent medical history and a list of active diagnosis. The policy revealed nurses would reconcile the list of medication from the discharge summary and admitting according to established procedures .contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain orders that are based on these findings.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected health conditions related to falls for 1 of 4 residents reviewed for accidents, out of a total sample of 50 residents, (#60). Findings: Resident #60 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/26/21. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for resident #60 revealed a Change in Condition form dated 9/25/20 regarding a fall at 5:30 AM. The document indicated the resident was injured, sustaining a hematoma on the back of her head. Review of the quarterly MDS assessment with assessment reference date of 10/19/20 revealed in Section J Health Conditions .J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment resident #60 was assessed as not having any falls. On 6/10/21 at 4:47 PM, the MDS Manager acknowledged the quarterly MDS dated [DATE] did not reflect resident #60's fall on 9/25/20. The MDS Manager indicated that question J1800 of the assessment should have been marked Yes and with option B selected to indicate an injury. The MDS Manager noted Section J of the assessment was inaccurate. The Resident Assessment Instrument instructions for Section J1800 read, Code 1, yes: if the resident has fallen since the last assessment. The document defined injuries to include hematomas. The facility policy and procedure titled Resident Assessment Instrument (undated) read, All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information.

Based on observation, interview and record review, the facility failed to follow physician's order for oxygen administration for 1 of 1 resident reviewed for respiratory care out of a total sample of 50 residents, #47. Findings: Resident #47 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS) assessment with assessment reference date 05/10/21 revealed that resident #47's cognition was severely impaired and he had memory problem. He required extensive assistance of 2 person for bed mobility and toilet use. He exhibited shortness of breath with exertion, while sitting at rest and when lying flat. He received oxygen while at the facility. Review of the resident's clinical record revealed a physician order dated 07/15/20 for oxygen at 2 liters per minute (LPM) via nasal cannula as needed for oxygen saturation below 90% and shortness of breath. On 06/07/21 at 11:42 AM, resident #47 was laying in bed with oxygen via nasal cannula attached to a concentrator located on the left side of his bed with the control knob set between 3.5 to 4 LPM. On 06/07/21 at 12:57 PM, resident #47 was sitting in a reclining chair in his room still attached to the oxygen concentrator set at 3.5 to 4 LPM. On 06/07/21 at 1:40 PM, Licensed Practical Nurse (LPN) A stated that resident #47 was on oxygen because his oxygen saturation levels had tendency to drop. LPN A stated resident #47 was on continuous oxygen at 4 LPM. She said she last checked his oxygen saturation before 1:30 PM which was 95% while on nasal cannula. On 06/07/21 at 1:53 PM, LPN A confirmed the oxygen setting for resident #47 was 4 LPM. She checked his physician orders and said the order was to give oxygen at 2 LPM via nasal cannula as needed for oxygen saturation below 90% and shortness of breath. She noted that resident #47 would not be able to touch his concentrator on his own. On 06/07/21 at 2:23 PM, the Unit Manager (UM) said that nurses were expected to check oxygen setting of residents whenever vitals signs were taken, usually once a shift. She explained the resident was on continuous oxygen and his concentrator was set at 3 LPM. The UM added that resident #47 did not usually have his oxygen when he was out of bed. She added that he could remove his nasal cannula but was unable to adjust concentrator. The UM checked the orders and acknowledged the current physician order did not state he could have oxygen continuously. Record review revealed that oxygen saturation readings from 06/03/21 to 06/06/21 ranged from 92% to 98%. The undated policy and procedure for oxygen administration indicated that a physician's order must be verified and reviewed according to facility protocol.

Based on interview and record review, the facility failed to follow up on pharmacy recommendations for 2 of 2 residents reviewed for unnecessary medications out of a total sample of 50 residents, (#22 and #35). Findings: 1) Resident #22 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Regimen Review (MRR) form dated 03/23/21 revealed that the consultant pharmacist made a recommendation to the attending physician that read, the patient is currently receiving a Proton Pump Inhibitor (PPI) for more than 12 weeks. Due to the updated F757, Unnecessary Medication Tag, the use of PPI should be periodically reviewed and the necessity for continuation documented as well as monitoring done for any adverse consequences. The Advanced Practice Registered Nurse (APRN) placed a check mark for the choice, This resident's PPI therapy has been re-evaluated and is appropriate for the continued use; dose reduction is contraindicated and the benefit of use outweighs the risks; Continue PPI therapy for 6 months; Continued use of any PPI therapy requires diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no progress note or any supporting documentation for its continued use. On 06/10/21 at 12:01 PM, the Director of Nursing (DON) acknowledged there was no progress note documented for the continued use of PPI. 2) Resident #35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed that on 08/17/20, the physician ordered [MEDICATION(S)] tablet 0.5 mg by mouth in the morning and 1 mg in the evening for [CONDITION(S)]. The MRR form dated 02/12/21 indicated that [MEDICATION(S)] requires an Abnormal Involuntary Movement Scale (AIMS) evaluation as soon as the medication is started and then every 6-12 months. The form did not indicate that it was reviewed or completed. On 06/10/21 at 4:40 PM, the Consultant Pharmacist recommendation read that it was necessary for AIMS evaluation to be completed to monitor for abnormal movements or adverse side effects. He also added that this would help in determining whether [CONDITION(S)] medications needed to be adjusted or discontinued. On 06/10/21 at 4:52 PM, the DON acknowledged the APRN did not complete an AIMS evaluation until 03/19/21. Policy and procedure on Consultant Pharmacist Reports dated February 2019 indicated that all non-urgent recommendations or irregularities must be addressed/reviewed within 30 days of consultant's monthly visit.