Every finding on record at Pine Grove Nursing Center

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. The facility failed to ensure Resident #1 was in safe position prior to incontinent care. Resident #1 rolled off her bed during incontinent care on 12/06/25.Resident #1 sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction (lower leg bone broken into multiple pieces tilted at an angle and slight displacement of the bone fragments) and a non-displaced fracture of the right distal femoral shaft(middle section of the femur-the bone breaks in one spot and remains aligned).This failure could place residents at risk of severe injuries.Findings included: Record review of Resident #1's undated face sheet indicated she was an [AGE] year-old female, admitted on [DATE], and her diagnoses included dementia (decline in mental abilities), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body following cerebral infarction (stroke), and cognitive communication deficit (difficulties in communication). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others. She had severe cognitive impairment (BIMS-7). She was dependent for rolling left to right. There were no falls noted. Record review of Resident #1's care plan dated 07/28/25 indicated Resident #1 needed assist with ADLS. Interventions included total assistance X 1 or 2. Record review of Resident #1's care plan dated 07/28/25 indicated Resident #1 had potential for falls related to weakness and hemiplegia/hemiparesis. Intervention included assist with ADLS as needed and call light in reach. Record review of Resident #1's fall risk assessment dated [DATE] indicated she was at high risk for falls. Interventions included needed and desired items in reach/easy access, low bed, and reminders to use call light. Record review of Resident #1's electronic care record printed 12/09/25 (EHR effective 06/24/25) indicated she was dependent for bed mobility. The care record did not indicate number of staff required. Record review of Resident #1's electronic care record printed 12/10/25 (EHR effective prior to 06/24/25) indicated Resident #1 was total dependence for bed mobility with support of 1 staff. Record review of nurse note dated 12/06/25 at 6:02 a.m., completed by LVN N indicated CNA W called LVN N to Resident #1's room. CNA W reported while she was changing Resident #1, she turned Resident #1 on her side and Resident #1 continued to roll. She was not able to catch Resident #1 before she fell. Resident #1 complained 10/10 of leg and back pain. Resident #1 had a skin tea to left hand and discoloration to bilateral knees. 5:29 am EMT Transport notified. 5:35 am Family, MD, Administrator, DON, ADON notified of transport. 5:42 a.m. EMT in facility. 5:52 a.m. EMT left facility. Record review of Resident #1's incident report dated 12/06/25 at 5:20 a.m., completed by LVN N indicated CNA W called LVN N to Resident #1's room. CNA W reported while she was changing Resident #1, she turned Resident #1 on her side and Resident #1 continued to roll. She was not able to catch Resident #1 before she fell. Resident #1 complained 10/10 of leg and back pain. Resident #1 had a skin tea to left hand and discoloration to bilateral knees. Neglect and Abuse were ruled out. The physician, DON, and family were notified. Actions included being changed to 2-person assist. Record review of Resident #1's hospital records dated 12/06/25 indicated she sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction. Record review of Resident #1's hospital records dated 12/07/25 indicated a non-displaced fractur of the right distal femoral shaft. Record review of CNA W's personnel record indicated she was oriented to resident care on 01/21/25 and incontinent care and fall prevention on 02/13/25. During an interview on 12/09/25 at 9:55 a.m., the DON said she was made aware on 12/06/25 Resident #1 fell, had pain and was sent to the hospital. The hospital never called the facility to give report of their findings. On 12/08/25, the facility found out she had sustained a left leg fracture and during surgery the surgeon noticed Resident #1 had right foot and leg swelling and determined she also had a right leg fracture. Resident #1's family member came to the family on 12/08/25 and questioned how he sustained her injuries. The DON said she showed the family member the bed height was set up in the highest position and how she rolled out of the bed onto the floor. Resident #1 had no history of falls in the facility. Resident #1 was on an air mattress that was set based on her weight. She said she was not in a bariatric mattress because she did not meet the criteria of a BMI over 50. She said staff are trained on bed mobility. She said Resident #1 was a 1-person assist for bed mobility. Staff are aware of resident care requirements through the care plan and care record. She said the facility determined the air mattress probably factored into Resident #1's fall during care and the facility had already begun the process of obtaining bolsters to prevent falls and a bariatric mattress. She said Resident #1's care plan would be reviewed and revised based on needs upon her return to the facility. She said Resident #2 would be a two-person assist for bed mobility upon her return to the facility. During an interview on 12/09/25 at 10:42 am., CNA W said Resident #1 was a 1-person assist for bed mobility and ADL care. She said she was going to change Resident #1. She said she rolled Resident #1 on to her weak right side and lifted her left leg to begin care. She said Resident #1 continued to roll off the bed. She said she held onto Resident #1's left knee and left arm as she fell to the floor. She said she was still hanging on to Resident #1's left leg and left arm when she was on the floor and she was hanging over the bed mattress. She said she left Resident #1 to get LVN N. She said LVN N was walking in the hall and came into the room immediately. She said Resident #1 was complaining of pain to her leg and back. She said Resident #1 was lying flat in the middle to her bed prior to the start of care. She said she did not pull Resident #1 closer toward her prior to turning her from her back onto her weak side. She said she felt there was not enough room and it would not have made any difference. She said she was trained on bed mobility and incontinence care. She said Resident #1 was a 1 person assist for ADL care. The surveyor attempted to call LVN N on 12/09/25 at 11:38 a.m. There was no answer. The surveyor left a voicemail message with contact information. LVN N did not respond as of the investigation exit. During an interview on 12/09/25 at 12:12 p.m., the DON said staff were supposed to pull residents toward them before they are rolled away. She said the risks of not completing bed mobility tasks as required could lead to falls with possible injuries. She said it was her expectations for staff to complete all care tasks as required to maintain resident safety. During an observation and interview on 12/09/25 at 1:22 p.m., Resident #1 in hospital and lying in bed. Resident #1 said she fell from her bed and hurt her leg. She said she rolled out of the bed. She could not recall how or why she fell from the bed. During an interview on 12/09/25 at 1:30 p.m., Family Member B, he said he did not feel the facility was neglectful. He said the surgeon was completing the surgery on Resident #1's left leg and noticed the right foot and right leg were swollen. He said a CT indicated there was a right leg fracture. He said Resident #1 was scheduled to have the second surgery for her right leg on 12/09/25. During an interview on 12/10/25 at 7:20 a.m., LVN T said Resident #1's level of care was listed in in her care plan. She said the care plan indicated 1 person for bed mobility. During an interview on 12/10/25 at 7:25 a.m., CNA P said Resident #1 was 1 person assist for bed mobility and care in bed. She said she had no difficulty performing care without additional staff assistance. During an interview on 12/10/25 at 7:35 a.m., CNA H said Resident #1 was 1 person assist for bed mobility and care in bed. She said she had no difficulty performing care without additional staff assistance. During an interview on 12/10/25 at 7:40 a.m., the DON said she found out on 12/09/25 (after surveyor entrance) from CNA W that there was not enough room to pull Resident #1 toward her before she began turning her for care. She said she had already ordered enabler bars and bolsters and was going to obtain a bariatric mattress. She said the care plan and care record would be updated to reflect Resident #1 was a 2-person assist upon her return to the facility. She said she started training staff on making sure there was adequate room for turning residents and the training would continue until all staff were trained. Record review of the facility's Fall Management policy dated 01/12/28 indicated Purpose: 1. The community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards.3. A resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing resident's rights and their need to maintain the highest practical level of function.Procedures: . 4. If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls - complete the Incident/Accident Report in the EHR.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 vaccine/medication storage refrigerators reviewed for labeling and storage. The facility failed to monitor and record temperatures of the refrigerator used for vaccine storage twice daily as required per the Centers for Disease Control (CDC) guidelines for vaccine storage. The facility failed to document date when opened on one vial of tuberculin skin testing (TST) solution in the vaccine/medication refrigerator. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.Findings included: During an observation and interview on 08/20/25 at 11:00 AM there was no log for recording temperatures for the vaccine/ medication refrigerator stored in the ADON office. The refrigerator had a temperature of 50 degrees, 4 degrees over the recommended 35-46 degrees Fahrenheit. The refrigerator contained three vials of tuberculin skin testing (TST) solution expiration date 10/2026. One of the three vials of tuberculin skin testing (TST) solution had been accessed and date no open date recorded on the vial or box and no initials. The medication storage directions indicated tuberculin skin testing solution was to be discarded after 30 days of opening. The ADON said she administered the TST to resident's and failed to document when she opened the vial. The ADON said she had not been checking the temperature or logging as required by standards of care. The ADON said she would start checking the temperatures twice daily and logging as required. The ADON said not maintaining the correct temperature and using the TST after it had expired to residents could be adverse reactions, medication not as strong as it should be, and false readings. During an interview on 08/20/25 at 11:15 AM the DON said that the ADON was responsible for ensuring vaccines were stored at correct temperatures, multi dose vials were labeled and expired medications were discarded. She said not maintaining vaccines at proper temperatures, not dating vaccines when opened and testing materials could cause an infective vaccination or false results of tuberculosis testing. During an interview on 8/20/2025 at 11:30 AM, the Administrator said the ADON and DON were responsible for tuberculosis testing. The Administrator said the tuberculin skin testing solution should not be given after the use by date and should be held at required temperatures. He expects that staff are trained accordingly and will oversee the DON to ensure all staff are trained. Record Review of policy and procedure titled Medication Storage dated 01/2018 revised date 1/2020 indicated, .Standard of practice: Staff will store medications in accordance with standard practice guidelines. Record review of tuberculin skin testing (TST) package insert states to dispose of medication 30 days after opening. Record review of https://www.fda.gov document dated 11/9/2020 reference 22. [NAME] S, et al. Effect of oxidation on the stability of tuberculin purified protein derivative (PPD) In: International Symposium on Tuberculin and BCG Vaccine. Basel: International Association of Biological Standardization, 1983. Dev Biol Stand 1986; 58:545-552. (Dispose of Vial 30 days after opening) Record review of https://CDC.gov/vaccines/storage document accessed 8/20/2025Indicated: Keep your storage units and vaccines within the appropriate temperature ranges. Store vaccines between 36- and 46-degrees Fahrenheit.Check and record storage unit min/max temperatures at the start of each workday. If your device does not display min/max temperatures, then check and record current temperature a minimum of 2 times (at start and end of workday).

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. The facility failed to store food in accordance with professional standards in that: 1. Dry storage items were improperly stored. 2. Frozen foods were unlabeled and open to air. These failures could place residents at risk for food contamination and foodborne illness. Findings: During an observation of the facility kitchen on 7/22/24 at 9:10 am revealed the following: *Flour was stored with a scoop inside the container. *Salt was stored with a scoop inside of an unoriginal container with no date or label. During an observation of the freezer in the facility kitchen on 7/22/24 at 9:15 am revealed the following: *a bag of Okra was stored in an opened box in an unsealed bag. *Squash was stored in a box without any label or date. *A left-over pecan pie dated 6/28 was stored in an uncovered pie tin. During an interview on 07/22/24 at 9:30 AM with the Dietary manager she said her expectation was for the dietary staff to label and store all items according to policy and regulation. She said not storing food items could spread food borne illness. During an interview on 07/22/2024 at 2:00 PM the Administrator said he expected the dietary staff to label and store foods as required. He said there was a risk of food borne illness if storage regulations were in followed by the dietary staff. Record review of a Food Storage Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored . by methods designed to prevent contamination . Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened .All foods are covered, labeled and dated .any item out of the original case must be properly secured and labeled. 49017

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #12, #30 and #259) reviewed for infection control. CNA A failed to perform hand hygiene during incontinent care for Resident #12 and failed to properly bag soiled linen before leaving Resident #12's room on 7/23/2024. CNA C failed to perform hand hygiene and follow EBP (enhanced barrier precautions) during incontinent care for Resident #30 on 7/23/2024. CNA E failed to perform hand hygiene during incontinent care for Resident #259 on 7/22/2024. These failures could place residents at risk for cross contamination and infection. Findings: 1. Record review of a facility face sheet dated 7/22/2024 indicated Resident #12 was an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. Record review of comprehensive care plan dated 4/14/2024 indicated Resident #12 was at risk for problems with elimination and an intervention was to provide peri-care after each incontinent episode. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #12 had a BIMS of 8 indicating mild cognitive impairment, was frequently incontinent of bowel and bladder and required maximal assistance with toileting hygiene. During an observation on 7/23/2024 at 9:55 am, CNA A provided incontinent care to Resident # 12. CNA A sanitized her hands and applied gloves. She opened Resident #12's brief, and he was soiled with feces. She cleaned the front area using disposable wipes. She then removed her gloves and applied new gloves without hand hygiene. Resident #12 was assisted to left side and back area was cleaned with disposable wipes. The soiled brief and bed pad was rolled under the resident and CNA A removed her soiled gloves and applied clean gloves without hand hygiene. She placed a clean linen pad and brief and assisted Resident #12 to his back. Soiled linen and brief were removed and placed at the foot of the bed. Clean brief applied and resident repositioned. CNA A then removed her glove from the right hand and carried soiled linen and brief openly with gloved left hand. CNA A exited the Resident #12's room with the soiled linen and soiled brief, walked down the hallway to the soiled linen closet and disposed of the linen and brief. She then removed her remaining glove and sanitized her hands. During an interview on 7/23/2024 10:05 am, CNA A said she had been a CNA for [AGE] years and had been trained on incontinent care and proper handling of soiled linen. She said she should have washed her hands in between glove changes, bagged the soiled linen, and removed her gloves and washed her hands before leaving the room. She said by not following infection control measures it could cause the spread of infection. 2. Record review of a facility face sheet dated 7/23/2024 for Resident # 30 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, osteoporosis, and myocardial infarction. Record review of a comprehensive MDS dated [DATE] for Resident #30 indicated that she had a BIMS score of 9 which indicated that she had moderate cognitive impairment. She was dependent with toileting and was always incontinent of bowel and bladder. Record review of a comprehensive care plan dated 7/18/2024 for Resident #30 indicated that she was on enhanced barrier precautions to prevent spread of multi-drug resistant organisms due to having a wound. Intervention read .Enhanced Barrier Precautions: gown and glove use during high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, wound care, and any skin opening requiring a dressing . Record review of resident's consolidated orders dated 7/23/2024 indicated that Resident #30 had the following order dated 7/18/24: .Enhanced Barrier Precautions (EBP) every shift Reason: stage 2 sacrum . During an observation and interview on 7/23/2024 at 9:58 am CNA C was asked what the blue dot beside Resident #30's name on door indicated. She said, I think it means they have an open wound She then was observed to provide incontinent care to Resident #30. She was observed to change gloves multiple times during care and did not wash or sanitize her hands between glove changes. She did not wear a gown while providing incontinent care. Upon exit from room, CNA C stated, I forgot to wash my hands when I changed my gloves. When asked if she was supposed to have worn a gown while providing resident care, she said Oh, yes, I think I was She then said they had been in-serviced multiple times and she knew she was supposed to be using enhanced barrier precautions due to residents wound, but she was nervous and forgot. Record review of an EBP Order Group Report provided by the facility indicated that Resident # 30 was on enhanced barrier precautions due to having a Stage 2 pressure ulcer to the sacrum. Record review of a facility in-service sign-in sheet dated 3/28/2024 and titled Enhanced Barrier Precautions (EBP) How to identify residents that require EBP, define and list high-contact care activities, PPE, and hand hygiene indicated that CNA C had signed indicating she had attended in-service and been trained on EBP. Record review of a facility in-service sign-in sheet dated 7/10/24 and titled EBP - Enhanced Barrier Precautions - Identifiers are blue bars by patient names on door indicated that CAN C had signed indicating she had attended in-service and been trained on how to identify residents with EBP. 3. Record review of a face sheet dated 6/4/2024 for Resident #259 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hypertension (high blood pressure), end stage renal disease (kidneys no longer work as they should to meet the body's needs), and chronic obstructive pulmonary disease (causes obstructed airflow from the lungs). Record review of a care plan revised 7/19/2024 for Resident #259 indicated an ADL self-care deficit and was dependent on staff for toileting hygiene. Record review of an Entry MDS assessment dated [DATE] for Resident #259. Resident #259 in facility for respite stay and discharged prior to admission MDS performed. During an observation on 7/22/2024 at 10:50 am, CNA E entered the room of Resident #259 to provide incontinent care. CNA E washed her hands and put on gloves. Supplies were in a plastic bag on the over bed table. CNA E opened the brief and pulled it down between Resident #259's thighs. CNA E removed a wipe from the plastic bag and wiped the resident's right inner thigh and folded it over and wiped the left inner thigh and placed the wipe in the trash. CNA E removed a wipe from the plastic bag and wiped down the middle of the vagina from front to back. CNA E rolled Resident #259 onto her left side. CNA E removed wipes from the plastic bag and wiped Resident #259's rectal area from front (vagina) to back (buttocks). CNA E removed a brief from the plastic bag and placed it underneath the resident's buttocks. Resident #259 was rolled onto her back and the brief was secured and the resident was repositioned in the bed. CNA E removed her gloves and washed her hands. CNA E failed to remove soiled gloves and wash hands after providing incontinent care and prior to placing clean brief on Resident #259. During an interview on 7/22/2024 at 12:25 am, CNA E said she had been employed at the facility for 4 years and worked on the 6 am-2 pm shift. She said the incontinent care provided to Resident #259 earlier, she should have washed her hands and changed her gloves between the soiled brief and clean brief. She said she had a check off on skills this year. She said residents could be at risk of infections if staff did not wash or sanitize their hands during incontinent care. During an interview on 7/24/2024 at 11:50 am, the DON said she and the ADON and Infection Preventionist were responsible for oversight of infection control in the facility. She said all staff had been trained on infection control measures when providing incontinent care and when a resident required EBP. She said training was completed on hire, annually and as needed throughout the year. She said if the infection control program was not followed by staff it could cause the spread of infections and expected all staff to follow the infection control program. During an interview on 7/24/2024 at 11:54 am, the Administrator said that the DON, ADON, and Infection Prevention nurse was responsible for the infection control program and oversight. He said he expected infection control measures to be followed daily and by not doing so could lead to the spread of infections. Record Review of a CNA competency evaluation dated 2/13/2024 indicated CNA A had been trained on incontinent care and infection control. Record review of a CNA Proficiency Skills Check dated 2/14/2024 conducted by the ADON for CNA C indicated she was satisfactory in perineal care, along with hand washing. Record Review of a CNA competency evaluation dated 2/13/2024 indicated CNA E had been trained on incontinent care and infection control. Record review of a facility policy titled Linen and Laundry Services dated January 2022 indicated, .6. soiled linen is bagged or put into carts where it is used (i.e., in the patient's/resident's room . Record review of a facility policy titled Hand Hygiene for Staff and Residents dated January 2022 indicated, .1. H. Hand hygiene is done after removal of medical gloves . Record review of a facility policy titled Enhanced Barrier Precautions dated April 1, 2024 read .This facility utilizes Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . and .Indications: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.b. Chronic wounds include, but are not limited to, pressure ulcers .3. High Contact Resident Care Activities: .f. Changing briefs or assisting with toileting . and .C. Communication: 1. Indicate the residents who are on EBP by subtle means, such as an alternate color of the resident's name badge on door, to maintain a home-like environment . 46436

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 3 of 12 resident's (Resident #5, Resident #43, and Resident #51) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure the refrigerator for Resident #43 did not contain an unlabeled, undated clear container of an unknown food item with a green, powdery substance covering it. The facility failed to ensure the refrigerator for Resident #5 and Resident #51 did not contain an unlabeled, undated clear container with fruit with a whit, grey fuzzy growth on the fruit and a zipper bag of food not labeled or dated. This failure could place residents at risk for food borne illnesses. Findings include: Resident #5 Record reviews of a facility face sheet dated [DATE] for Resident #5 indicated that she was a [AGE] year old female admitted to the facility on [DATE] with diagnosis including Parkinsonism (a group of conditions that affect movement and mimic Parkinson's disease) , Chronic Obstructive Pulmonary Disease (causes obstructed airflow from the lungs) , hypertension (High blood pressure) , and diverticulosis (development of small sacs in the wall of colon) . Record review of an annual MDS dated [DATE] for Resident #5 indicated she had a BIMS score of 15, which indicated that she is cognitively intact. She required set up assist with eating. Record review of a comprehensive care plan dated [DATE] for Resident #5 indicated that she has a cognitive deficit in decision making. Resident #43 Record review of a facility face sheet dated [DATE] for Resident #43 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (a group of symptoms affecting memory, thinking and social abilities), chronic atrial fibrillation (a type of heart arrhythmia that lasts longer than 12 months), and hypertension (high blood pressure). Record review of a quarterly MDS dated [DATE] for Resident #43 indicated that she had a BIMS score of 6, which indicated that she had severe cognitive impairment. She required set-up or clean up assist with eating. Record review of a comprehensive care plan dated [DATE] for Resident #43 indicated that she had severe cognitive impairment and poor decision making. Resident #51 Record review of a facility face sheet dated [DATE] for Resident #51indicated that she was an [AGE] year old female admitted to the facility on [DATE] with diagnosis including dementia (A group of symptoms that affects memory, thinking and interferes with daily life) , arthritis (A condition with swelling and tenderness of one or more joints) , anxiety (Fear characterized by behavioral disturbances.) , and cerebral infarction (- the pathologic process that results in an area of necrotic tissue in the brain) . Record review of a quarterly MDS dated [DATE] for Resident #51 indicated that she had a BIMS score of 5, which indicated that she had severe cognitive impairment. She required set up assistance with eating. Record review of a comprehensive care plan dated [DATE] for Resident #51 indicated that she had severe cognitive impairment and deficit in decision making. During an observation on [DATE] at 9:10 am a clear container was observed in Resident #43's refrigerator. The container was unlabeled and undated. A green, powdery substance was observed on an unknown food item that was inside container. During an observation on [DATE] at 12:00 pm Resident #43 was observed feeding self in dining room. She was unable to appropriately answer questions. During an observation on [DATE] at 9:40 AM Resident #5 and Resident #51's personal refrigerator had food that was not labeled or dated. The refrigerator contained a clear plastic container of cut fruit that had an appearance of white, grey fuzzy growth on part of the fruit. There was a zipper bag that contained fried meat that was not labeled or dated. During an interview on [DATE] at 9:37 am CNA A said the housekeeping supervisor was responsible for cleaning out resident refrigerators. During an interview on [DATE] at 11:40 am Housekeeping Supervisor said was responsible for cleaning out residents' personal refrigerators and she cleans them out about once per month. She said she does not have a set schedule and does not have documentation showing where she had done it. She said if residents consumed old or outdated foods it could make them sick. During an interview on [DATE] at 12:00 PM Resident #5 said her family brought her food from home and from the store and she stored it in the personal refrigerator. She said her roommate also stored things in the refrigerator at times. She said the fruit and the other food items belonged to her. She said she cleaned her refrigerator sometimes. She said that staff would clean the refrigerator out if she asked them to. Resident #5 said she would not eat spoiled food and that she would look at the items or smell them before consuming them. During an interview on [DATE] at 5:15 PM Administrator said he was aware that some rooms had items in the personal refrigerators that were not dated and appeared expired. He said the refrigerators were checked for unlabeled and expired items. He said resident families often brought in foods and that the family did not always label the food items and did not remove expired foods. He said housekeeping staff was responsible for cleaning the refrigerators monthly. During a joint interview on [DATE] at 10:30 AM with Administrator and DON, DON said her expectation was that all items in personal refrigerators be labeled with a date when brought in. Administrator said the facility was looking into adopting a new personal food policy. He said the personal refrigerators will become part of the QA/QI process. He said families were responsible for the items in the personal refrigerators and that more education with the families was needed. He said expired items could be consumed by the residents and cause illness. Record review of a facility policy titled Resident Personal Refrigerators dated [DATE], read .Housekeeping staff will empty and clean resident refrigerators on a routine monthly basis . and .Education will be provided to family to label food with resident name, room number, and date brought into facility. All food items will be discarded at day 7 . 49017

Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 12 residents (Resident #12, #48, and #35) reviewed for ADLs. The facility failed to provide incontinent care to Residents #12 and #48 in a timely manner on 7/22/2024. The facility failed to provide denture care for Resident #35 on 7/23/2024. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, lack of dignity, and poor health. Findings: 1. Record review of a facility face sheet dated 7/22/2024 indicated Resident #12 was an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. Record review of comprehensive care plan dated 4/14/2024 indicated Resident #12 was at risk for problems with elimination and an intervention was to provide peri-care after each incontinent episode. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #12 had a BIMS of 8 indicating moderate cognitive impairment, was frequently incontinent of bowel and bladder and required maximal assistance with toileting hygiene. Record review of ADL flow sheet dated 7/22/2024 at 3:33 am indicated Resident #12 received care for bowel incontinence episode on 7/22/24 at 1:56 pm. Further review revealed there were no other entries dated prior to 7/22/24. During an interview on 7/22/2024 at 9:30 am, Resident # 12 said he needed to be changed and had a diaper full. He said the staff changed him this morning before breakfast and the staff get to him when they get to him, and it was irritating. During observations of on 7/22/2024 revealed Resident #12 was soiled with urine and feces at the following times: *10:05 am, *10:30 am, *10:55 am, and *11:10 am. 2. Record review of a facility face sheet dated 7/22/2024 indicated Resident #48 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis to one side following a stroke). Record review of a comprehensive care plan dated 3/14/2024 indicated Resident #48 was at risk for problems with elimination and an intervention was to check resident every two hours and assist with toileting as needed. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #48 had a BIMS of 9 indicating moderately impaired cognition, always incontinent of bowel and bladder and dependent on toileting hygiene. During an interview on 7/22/2024 at 9:25 am Resident # 48 said he was wet and had not been changed since before breakfast. He said he was unsure of exact time but said breakfast was around 8:00 am and the lady came in but did not change his brief. During observations and interviews on 7/22/2024 at 10:05 am, 10:30 am, 10:55 am and 11:10 am Resident # 48 remained soiled with urine and had an odor. He said no one had been by to change him. During an interview on 7/22/2024 at 11:15 am, CNA A said she had been a CNA for [AGE] years and had been trained on ADL care and care should be given every 2 hours. She said she checked Resident #12 and #48 at 8:15 am and they were wet but did not change them at that time. She said she had not gotten back around to providing care to them. She said ADL care should be provided every 2 hours and by not doing so could cause skin breakdown. During an interview on 07/24/24 at 9:17 am, LVN B said she had been a nurse for 3 years and was the charge nurse for Resident #12 and #48. She said she had not noticed that Residents #12 and #48 were soiled when she rounded. She said incontinent care should be done every 2 hours to prevent skin breakdown and infections. 3. Record review of a facility face sheet dated 7/22/2024 indicated Resident #35 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and cognitive communication deficit (which can affect social language skills, attention, memory, reasoning, judgment, and executive functions). Record review of comprehensive care plan dated 6/6/24 indicated Resident #35 had self-care deficits and to assist with ADL's and had altered nutritional status had required dentures. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #35 had a BIMS of 6 indicating severe cognitive impairment, section L indicated no natural teeth. Record review on 7/23/2024 of Resident #35's CNA ADL flow sheet dated 7/23/2024 revealed no interventions for denture care were included. Record review on 7/24/2024 of Resident #35's CNA ADL flow sheet dated 7/24/2024 indicated corrections had been made to include interventions for denture care. During an interview on 7/23/2024 at 2:40 pm, CNA D said was assigned to work to Resident #35 care most evening shifts. CNA D said she helped Resident #35 with oral hygiene every day and Resident #35 does not have dentures. During an observation and interview on 7/23/2024 at 3:20 pm, Resident #35 removed both upper and lower dentures to demonstrate how she cleans them. The dentures had a brown discoloration and a white crusty build up on the outside. Resident #35 wiped the dentures with sanitary wipes and large white and brown food particles were removed and fell on her dress. CNA D said she thought Resident #35 had her real teeth and had only been assisting with brushing them. During an interview on 7/23/2024 at 3:25 pm with ADON she said she was not aware CNA D was not providing denture care. During an interview on 7/23/2024 at 3:42 pm with ADON she said Resident #35 had been identified as having full top and bottom dentures at admission, but interventions were not included in CNA ADL flow sheet. During an interview on 7/24/2024 at 11:56 am, the DON said she and the ADON and charge nurses were responsible for oversight of ADL's. She said ADL care documentation was reviewed almost daily by herself or the ADON. She said the CNA's should have been documenting each occurrence of incontinence and each resident that required denture care that task should have been on their ADL task for the CNA. She said she expected incontinent care to be provided timely to prevent skin breakdown and expected residents to receive denture care to prevent oral infections. During an interview on 7/24/2024 at 12:01 pm, the Administrator said the DON and ADON were responsible for oversight of all ADL's. He said nurse management should be reviewing ADL care documentation daily and expected all residents to receive all ADL care that they required per their care plan and policy. He said if ADL care was not completed it could affect the resident's health. Record review of a facility policy titled Perineal Care dated April 22, 2024 indicated, .staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . Record review of policy revised 1/20/20 titled Denture Care policy Staff will provide denture care for residents in accordance with standard of practice guidelines. 50818

Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 16 residents reviewed for call lights. (Resident #9 and Resident #19) The facility failed to ensure Resident #9's and Resident #19's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings included: 1.Record review of a facility face sheet dated 07/22/2024 indicated Resident # 9 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of muscle weakness (generalized). Record review of a comprehensive care plan revised 01/04/2024 indicated to assist with toileting as needed and Resident # 9 had a history of falls while toileting. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 9 had a BIMS of 06 indicating severe impaired cognition, impairment of both lower extremities and unable to stand. 2. Record review of a facility face sheet dated 07/22/2024 indicated Resident #19 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of muscle weakness (generalized). Record review of a comprehensive care plan revised 06/06/2024 indicated Resident # 19 had intervention to take resident to the toilet at the same time every day. Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 19 had a BIMS of 15 indicating intact cognition, no impairment of lower extremities, and received partial assistance with toileting including toilet transfers. During an observation and interview on 07/22/24 at 9:45 AM room [ROOM NUMBER], the bathroom call light had a metal string 4 inches long sticky out of the wall, no string attached. Resident #9 said she uses the restroom occasionally and the staff assist her to transfer to the toilet if she does use it. During an observation and interview on 07/23/24 at 10:00 AM room [ROOM NUMBER] Resident #19 says he uses the bathroom to wash up and uses the toilet. The call light string does not reach the floor by 2 feet. During an observation and interview on 07/23/24 2:15 PM, Housekeeper F was cleaning a resident bathroom in room [ROOM NUMBER]. Housekeeper F said she tried to pay attention to the call lights in the restrooms when cleaning residents' bathrooms. Housekeeper F said she did not see anything wrong with the restroom. Housekeeper F said she would report the missing string to the Maintenance Director for replacement. She said she has worked at the facility for about 5 months. She said she would go get the maintenance man to attach longer strings to rooms [ROOM NUMBERS]. Housekeeper F said there was risk of a resident lying on the floor after a fall if they could not reach the call light string. During an interview on 07/24/24 08:00 AM the Maintenance Director said the call light strings in the bathroom should be to the floor in case a resident falls they would be able to call for help. He said that the resident could lie on the floor until someone made rounds if the strings were missing. He said the housekeeper told he yesterday that room [ROOM NUMBER] and room [ROOM NUMBER] needed longer strings in the bathrooms and he corrected the problem. He said he made rounds in the rooms periodically to check functioning of the call light system, but there was no formal list for checking safety items in rooms. During an interview on 07/24/24 08:30 AM the Administrator said the bathroom call lights should have a string that fall near the floor. He said the resident could not be able to call for assistance if the string was missing or was not long enough for the resident to reach it. Record review of a facility policy dated 1/19/2023 Call lights Answering Policy: The staff will provide an environment that helps meet the resident's needs by answering call lights appropriately.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers. The findings were: Record review of a facility face sheet dated 07/22/2024 indicated Resident #18 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of muscle weakness (generalized) and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 01/04/2024 indicated Resident #18 was at risk for problems with elimination and to check resident every two hours and assist with toileting as needed. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #18 had a BIMS of 12 indicating moderately impaired cognition, impairment of both lower extremities and unable to stand. During an observation on 07/22/2024 at 10:11 AM, of a Hoyer lift sling in Resident #18's room, the colored connection tabs were faded light in color. The green edges are frayed with strings showing, the care label was illegible and shrunken, the sling has a handwritten date of 06/2018. During an observation on 7/23/2024 at 08:53 AM, Resident #18 was sitting in her chair with a Hoyer lift sling underneath her. The straps are faded light purple, light blue with the care tag illegible. During an observation and interview on 07/23/2024 at 08:58 AM, linen closet on A hallway accessed by CNA D, revealed there were 3 Hoyer lift slings inside that were faded in color, care tag labels are frayed and illegible. One of the three slings had a handwritten date 02/2019 on the label. CNA Daid she worked at the facility for months; she would take any Hoyer sling out of service that had tears or fraying and does not know how long they stay in service before they are removed. She said she had several residents that required a Hoyer lift for transfers. CNA D said that if a sling was not available on the hallway she would go to the linen closet and retrieve one for use. CNA D said the resident could suffer an injury or could be scared to get up with a lift if they were dropped. During an interview on 07/23/2024 at 09:05 AM, the ADON said she worked for the facility for many years. She said provided education to the staff regarding use of the Hoyer lift slings and when to remove them out of service. The ADON said she was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible that indicated it had been worn, bleached or was compromised. The ADON said the resident could suffer in injury of the straps broke. During an interview with the DON on 07/23/2024 at 09:15 AM, the DON said she worked for the facility for almost [AGE] years. She said she removed slings if they have holes, frays or strings but she was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible that indicated it had been worn, bleached or was compromised. The DON said the resident could suffer in injury of the straps broke. During an interview on 07/23/2024 at 9:30 AM, the Administrator said he was aware the slings required special care, the facility needed to follow manufacturers suggested practices but did not know the color change could indicate the Hoyer lift slings should not be used. He said if the sling broke it could cause injury to the resident being transferred. A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 07/23/2024 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Mechanical Lifts dated 05/2023 indicated .Residents will be assisted with their Activities of Daily Living, utilizing lifts according to manufacturer's guidelines . e. Check to ensure the sling is in good working condition with no torn or ripped area, etc.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The dish machine tested at 10 ppm of chlorine and the temperature gauge was stuck at 110 degrees F. The grease in the deep fryer was black. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 06/05/23 at 9:04 AM surveyor entered the kitchen and noted the calendar log for the dish machine had not been completed for 06/05/23, and the sanitizer bottle attached to the dish machine was empty. Dietary Staff F was standing at the dish machine, and it was running washing dishes. The surveyor requested staff to test the dish machine. Nutrition Aide F tested the dish machine with Auto-Chlor precision chlorine test strip. The machine tested at 10 ppm and the thermometer on the dish machine never moved off 110-degrees F. Nutrition Aide F showed the test strip to the surveyor, and she was unable to tell the surveyor what correct reading the test strip should read. (50-100 ppm). The temperature of the water should reach 120 degrees F. during the final rinse. Nutrition Aide F said she had worked at the facility for [AGE] years and was taught to test the dish machine by the previous dietary manager. Nutrition Aide G attempted to test the dish machine and it tested at 10 ppm. She showed the test strip to the surveyor and did not know what it should read. Nutrition Aide G said she has worked at the facility for five years and was taught to test the machine by the previous dietary manager. During an observation on 06/05/23 at 09:15 AM, the grease in the deep fryer was black. During an interview on 06/05/23 at 9:18 AM the Dietary Manager said they usually changed the oil in the fryer every two weeks. She said they change the oil after they fry fish. Black oil indicates the oil is dirty and could become rancid. During an interview on 06/06/23 at 9:20 AM, The DM said they did not have any cooking oil available to change the oil in the fryer over the weekend. She said they usually change it on Saturday or Sunday after they fry fish on Friday. She said she had to go to the store and buy oil to change the grease in the fryer. She said not changing the oil could make the residents sick. During an interview on 06/06/23 at 9:15 AM with the Dietary Manager she said that she usually tested the dish machine herself first thing every morning, but she had not gotten to it yet. She said her expectation for the dish machine was for the staff to be able to correctly test the dish machine as required. She said they called ECO-Lab, and they came out and replaced the thermostat on the dish machine this morning. She said the dish machine not sanitizing the dishes could make the residents sick. During an interview on 06/07/23 at 1:30 PM, the Administrator said his expectations was for the kitchen staff to follow the policy and keep the dish machine in working order and check the sanitizer and temperature of water at the start of use. Record review of a policy, Titled: Cleaning Dishes in the Dish Machine, effective August 1, 2018 reflected: Dishes and cookware are washed and sanitized after each meal. Procedure: 1. Check the dish machine gauges and chemicals at the start and throughout the use to ensure proper temperatures/adequate supply, respectively. Log data as instructed. Refer to the manufacturer's directions for correct temperature and sanitizer (low temperature dish machine only) setting.

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 9 of 12 months (May 2022, June 2022, July 2022, August 2022, October 2022, December 2022, January 2023, February 2023, and March 2023) reviewed for pharmacy services. The facility did not have a licensed pharmacist and two witnesses initial the attached pages of controlled medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion. Findings: During a record review of the facility's drug destruction log for the last 12 months, the drug destructions for controlled drugs dated 05/24/22, 06/24/22, 07/26/22, 08/26/22, 10/21/22, 12/16/22, 01/13/23, 02/08/23, and 03/10/23 indicated that the attached pages of medication destruction did not include the initials of the consultant pharmacist and two witnesses. During an interview on 06/07/23 at 9:50 a.m., the ADON said that she was unaware that there had to be two witnesses initialing each page and that she thought the cover sheet was all that was needed. She said that she took this position in late 2022 and would implement a new system that would ensure all attachment pages were witnessed appropriately going forward. During an interview on 06/07/23 at 9:55 a.m., the DON said that she was unaware of the need for each attachment page to be witnessed by two witnesses. She said that she would ensure all pages were signed and initialed appropriately going forward. She said that she did not think a drug diversion could happen and could not think of any negative outcomes that could occur. During an interview on 06/07/23 at 1:14 p.m., the ADMIN said that he would check the regulations with the pharmacist to ensure the drug destruction occurred appropriately, and said that going forward, he expected his staff to follow correct policy regarding drug destruction. Record review of facility policy titled Disposal of medications, syringes, and needles: Disposal of Medications dated 2007 indicated .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations . Record review of 22 TAC S303.1 Destruction of Dispensed Drugs accessed online 06/07/2023 at https://texreg.sos.state.tx.us/ indicated; (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse.

46273 46436 Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident # 24, Resident # 35, and Resident #60) reviewed for infection control. 1. CNA A failed to properly handle soiled linen and soiled brief for Resident #24 after personal care. 2. CNA B failed to properly handle soiled linen and soiled brief for Resident #60 after personal care and failed to appropriately perform hand hygiene after incontinent care. 3. Treatment nurse failed to clean the scissors used to cut wound care dressings for Resident #35 and she stored the scissors in her pocket. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of facility face sheet dated 6/06/2023 indicated Resident # 24 admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypercapnia (impaired breathing that causes increased carbon dioxide in the blood). An Admission MDS dated [DATE] indicated Resident #24 had a BIMS of 10 indicating moderate cognitive impairment and required maximum assistance with bathing and toileting. A Care plan dated 04/11/2023 indicated a self-care deficit and required assistance with self-care. During an observation on 06/05/23 at 09:57 AM Resident #24 was receiving personal care from CNA A. During an observation on 06/05/23 at 10:06 AM Resident # 24 had soiled linen including a bed sheet, incontinent pad, and a soiled brief on the floor bedside their bed. During an interview on 06/05/23 at 10:21 AM CNA A stated she had been a CNA for 5 years. She stated when she provided incontinent care to Resident #24, she should have placed her soiled linen and soiled brief in a bag to prevent contaminating the floor in the resident's room. She stated she had been trained on proper handling of soiled linens annually and by not doing so could be an infection control issue for the resident and others. 2. Record review of facility face sheet dated 6/06/2023 indicated Resident # 60 admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (impaired breathing that causes low oxygen to the brain), severe sepsis (infection in the body), and urinary tract infection. An Admission MDS dated [DATE] indicated Resident #60 had a BIMS of 08 indicating moderate cognitive impairment and required extensive assistance with transfers, dressing, and toileting. A Care plan dated 05/04/2023 indicated a self-care deficit and required extensive assistance. During an observation on 06/05/23 at 10:12 AM Resident #60 received incontinent care from CNA B. CNA B placed soiled wet washcloths and towels on the floor beside the resident bed and did not change her gloves after providing incontinent care. CNA B wore the same soiled gloves to dress and transfer Resident #60 into her wheelchair. During an interview on 06/05/23 at 10:41 AM CNA B stated she had been a CNA for 1 year. She stated she should have had a bag for her dirty linens and placed the soiled washcloths and towels in a bag not on the resident's floor. She stated she should have removed her gloves after incontinent care, washed her hands, and applied clean gloves before applying a clean pullup, dressing the resident, and transferring her to the wheelchair. She stated she had been trained on infection control measures including handling soiled linens. She stated the risk of not following infection control measures could be increased risk of infection to the resident. During an interview on 06/07/23 at 09:01 AM the IP nurse stated she oversees the infection prevention program and staff training. She stated all nursing staff are trained on hire, annually and as needed regarding infection control measures. She stated staff should change their gloves after incontinent care, wash their hands and then apply new gloves before performing the next task. She stated all soiled linen should be disposed of using standard precautions and not placed on the floor. She stated the risk of not following infection control measures would be cross contamination. She stated she expected all staff to following the training they have had and will begin retraining all staff. 3. Record review of a face sheet dated 6/6/2023 for Resident #35 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of nutritional deficiency (body does not get enough vitamins and minerals), anorexia (loss of appetite for food), hypertensive chronic kidney disease (damage to the kidney caused by high blood pressure), and hypertension. Record review of active physician orders dated 5/17/2023 for Resident #35 indicated an order to clean a wound to the sacrum (tailbone) and lower back with normal saline or wound cleanser, pat dry, cover wound bed with calcium alginate (an absorbent wound dressing that promotes healing) and cover with dry dressing every shift until resolved. Record review of a care plan for Resident #35 dated 6/6/2023 indicated she had skin breakdown as evidenced by stage 4 (deep wound reaching the muscles and bones) to her sacrum and lower back with interventions to cleanse stage 4 to lower back and sacrum with normal saline or wound cleanser, pat dry, cover wound bed with calcium alginate and cover with dry dressing until resolved daily. Record review of a Quarterly MDS assessment dated [DATE] for Resident #35 indicated she had severe impairment in thinking with a BIMS score of 3. She required total dependence with personal hygiene with one person assist. She had two pressure ulcer/injuries at stage 4. During an observation on 6/6/2023 at 10:00 AM, the Treatment nurse provided wound care to Resident #35. The Treatment nurse gathered supplies in the hallway prior to entering Resident #35's room and placed the items on a tray. Wound care was provided to Resident #35's sacrum and lower back. LVN washed and sanitized her hands, and wore gloves throughout the treatment. The Treatment nurse removed scissors from her pocket and cut the calcium alginate to fit the wound and placed it on Resident #35's lower back and sacrum without cleaning them. During an interview on 6/6/2023 at 10:20 AM, the Treatment nurse said she had been employed at the facility since January 16, 2023. She said she had received training on wound care from the previous ADON and the IP. She said she should have sanitized her scissors before the treatment and placed them on the tray and not have them in her pocket. She said she should have precut the calcium alginate beforehand. She said corporate staff did checkoffs with her on basic dressing and wound care in February 2023. She said a resident could be at risk for contamination from the scissors being in her pocket and cutting the dressing before cleaning them. She said it could cause an infection. Record review of a facility training for the Treatment nurse dated 2/22/2023 indicated she had a competency skills checkoff on infection control for wound care training by the Regional nurse consultant. During an interview on 6/6/2023 at 10:30 AM, the IP nurse said she had been employed at the facility since July 2022. She said she did not train the treatment nurse on wound care and that the wound care training was done by the previous ADON. She said she did provide the Treatment nurse training on hand washing and infection control but not anything related to wound care. During an interview on 6/06/2023 at 11:35 AM, the DON said the Treatment nurse had been trained on wound care by the previous ADON. She said the treatment nurse had received a computer-based training on wound care and would be taking another online course on wound care soon. She said residents could be at risk for infection. She said going forward the treatment nurse would be enrolled in another wound care training and staff would receive more education on wound care. During an interview on 6/7/2023 at 11:00 AM, the Regional nurse said she had been at the facility since November 2022. She said she did train with the Treatment nurse on wound care and documentation. The Regional Nurse said she observed the Treatment nurse perform wound care treatments and was instructed on cleaning equipment before use such as scissors. She said scissors were never to be stored in the pockets of staff. She said a resident could be at risk of infection. During an interview on 06/07/23 at 09:06 AM the DON stated the IP oversees the staff training program and reviewed training and reports. She stated she expected all staff to follow standard precautions to avoid spread of infection. She stated she would see that all staff were retrained on infection measures. During an interview on 06/07/23 at 1:11 PM the Admin stated the DON was responsible for overseeing the infection control program and the IP was responsible for training. The risk to resident could be a negative effect from exposure to something that was infectious. The DON stated he expected that all staff follow infection control guidelines. Record review of undated facility policy titled Linens indicated, .The facility staff should handle all used laundry as potentially contaminated and use standard precautions. Contaminated laundry is bagged or contained at the point of collection. Record review of facility policy and procedure dated January 12, 2020, titled Perineal Care indicated' .Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection. 9. Dispose of gloves and used supplies and perform hand hygiene. 10. Apply new gloves and place new brief. Record review of a facility policy titled Treatment of Wounds: Dressing Changes dated July 2018 indicated, .2. Follow standard precautions and infection control methods .

Based on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 21 residents reviewed for call lights. (Resident #6 and Resident #316). The facility failed to ensure Resident #6 and #316's emergency call light in the bathroom would reach the floor. The call light cord for Resident #6 was too short and Resident #316's was wrapped around the support bar. This failure could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings include: Record review of a face sheet dated 6/6/23 indicated that Resident #6 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, Chronic obstructive pulmonary disease, and Type 2 diabetes. Record review of a Quarterly MDS dated [DATE] for Resident #6 indicated that she had a BIMS score of 15 indicating that she was cognitively intact. MDS Section G indicated that the resident required supervision and setup help only for toilet use. Record review of a face sheet dated 6/7/23 for Resident #316 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Repeated falls, chest pain, Gastro-esophageal reflux disease, and Chronic obstructive pulmonary disease. Record review of a comprehensive MDS dated [DATE] indicated that Resident #316 had a BIMS score of 03, indicating severe cognitive impairment. MDS section G indicated that the resident required maximum assist of two or more persons to use the toilet. During an observation on 06/05/23 at 10:08 a.m. the call light in the restroom of room [ROOM NUMBER] (Resident #6's room) was observed to be too short, and the end of the string ended above the grab bar. During an interview on 06/05/23 at 12:25 p.m., Resident #6 said that she used the restroom independently. She said she had not fallen, but if she were on the floor that she would not be able to reach the string to pull the light. During an observation and interview on 06/05/23 at 09:40 a.m. the call light in room [ROOM NUMBER] (Resident #316's room) was observed to be wrapped around the grab bar in the restroom. Resident #316 said that it had been like that since he had been admitted on [DATE]. He said that if he fell , he would not be able to reach the string to pull it. During an interview on 06/05/23 at 04:15 p.m., CNA E said that staff were always in the restroom with Resident #316, and he would never be in there alone. She said that Resident #6 used the restroom independently. Upon observing the call light in the restroom of Resident #6, she said that if the resident were to fall, she would be unable to reach the string to call for help. During an interview on 06/05/23 at 04:19 p.m. the maintenance director said that he was responsible for ensuring call lights in restrooms were accessible. He said that if the resident fell , she would be unable to reach the call light and call for help if the string were too short. During an interview on 06/07/23 at 01:14 p.m. the ADMIN said that going forward, he would expect his staff to ensure all call lights were accessible to residents and in proper working order. He said that if residents were not able to reach the call light, it could delay them getting the help they needed. Record review of facility policy titled Safety systems for residents with a date of January 12, 2020, indicated .Call light is in place and attached within reach of resident at all times .

Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking, smoking areas, and smoking safety for 1 of 6 residents reviewed for smoking (Resident #53). The facility failed to keep cigarette butts out of the trash can in the smoking area (Front Porch of the Facility), and there were no ash trays or a red metal trash cans available for residents to extinguish their cigarettes. The residents were putting there cigarettes out on the bricks of the building. The residents were then placing the cigarettes in a plastic garbage can with paper goods in it This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings included: Record review of the Face Sheet dated 07/13/21, indicated Resident #53, admitted [DATE], was [AGE] years old with diagnosis of Schizophrenia (mental Disorder), Atherosclerotic heart disease of native coronary artery, (hardening of the arteries), Anemia, Essential (primary) hypertension, (high blood pressure). Record review of a Quarterly MDS assessment for Resident #53 dated 4/8/23 indicated he had a moderate impairment in thinking with a BIMS score of 12. A BIMS of 8-12 indicates the resident is moderately impaired. Record review of the care plan for Resident # 53 dated 4/14/23 indicated he was a smoker with interventions of safe smoking assessment as needed, staff supervision and he was an unsafe smoker. Counseled on designated smoking areas. During an observation on 06/05/23 at 1:55 PM the front porch of the facility was designated as a smoking area. There were no ash trays or red trash cans available for residents to extinguish their cigarettes. There was a large plastic trash can with cigarette butts and paper in the trash can. During an interview on 06/06/23 at 2:30 PM with Resident #53 he said they only smoke out front on the porch when it is raining, otherwise they use the smoking gazebo, located out back. He said they use the bricks on the building to extinguish their cigarettes. During an observation on 06/07/23 at 11:20 AM of the smoking area on the front porch there were multiple ash marks on the bricks, and concrete near the sitting area. There were multiple burn holes in the cushions of the furniture. During an interview on 6/7/23 at 1:00 PM, the Administrator said that the front porch area was used for smoking by staff, residents, and visitors during bad weather. He said there was a fire extinguisher out on the front porch. The Administrator said there were no ash trays or a smoking can out there because he preferred, they used the smoking area out back. He said he was not aware that cigarettes were being put out on the side of the building. He said he was going to reevaluate the front of the building being used as a smoking area. He said there was a risk of fire and injury if the cigarettes were not extinguished properly. Record review of a smoking risk assessment for Resident # 53 dated 4/6/23 indicated he was a safe smoker. Record review of a facility policy titled Smoking Policy, undated, reflected .Residents will smoke with appropriate supervision in the designated smoking area. The designated smoking areas are as follows: Front porch of the facility, smoking gazebo, located outside c hall exit and bench area/under tree outside c hall exit .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 16 resident personal refrigerators reviewed for food safety (Resident #315 & Resident #11). The facility failed to ensure the refrigerator for Resident #315 had a thermometer for checking the temperature and that the refrigerator for Resident #11 did not contain an unlabeled, undated sandwich, or expired cranberry juice. This failure could place residents at risk for food borne illnesses. Findings include: Record review of a resident face sheet dated [DATE] indicated that Resident #315 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD), Heart failure, unspecified, and opioid dependence, uncomplicated. Record review of a BIMS assessment dated [DATE] for Resident #315 indicated that he had a BIMS score of 15 indicating that the resident was cognitively intact. Record review of a face sheet dated [DATE] indicated that Resident #11 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Cerebral infarction, End stage renal disease, Type 2 diabetes mellitus, and Dependence on renal dialysis. Record review of a comprehensive MDS dated [DATE] for Resident #11 revealed that she had a BIMS score of 15 indicating that she was cognitively intact. During an observation and interview on [DATE] at 09:35 a.m., Resident #315's personal refrigerator was observed with no thermometer to allow staff to check temperature. Resident #315 stated that he was unaware if any staff had checked his refrigerator as he had only admitted to the facility a few days ago and the refrigerator was in the room when he admitted . The refrigerator was observed to contain several protein shakes. During an observation on [DATE] at 10:17 a.m., Resident #11's personal refrigerator was observed with a sandwich in an open plastic bag with no date and no label. Bread on the sandwich was hard; also observed a bottle of cranberry juice with an expiration date of [DATE]. During an interview on [DATE] at 11:00 a.m. the DON was unable to say who was responsible for checking resident refrigerators for temperature and expired food items. During an interview on [DATE] at 10:11 a.m. the HSK supervisor said that she was responsible for checking the temperatures in resident refrigerators, but that some days she did not have time to do it. She said that she does keep a log when she checks the temperatures. She said that she was unaware until yesterday that she was also responsible for cleaning out the refrigerators in resident rooms and ensuring that all expired foods were disposed of. She said that she would be doing that going forward. She said that residents could be at risk of consuming ruined foods if the refrigerator was not keeping foods at the correct temperature or if they consumed expired foods. During an interview on [DATE] at 09:55 a.m., the DON said that if the temperature checks on resident refrigerators were not done appropriately and the temperature started fluctuating and no one realized it, that it could potentially cause food spoilage and food borne illnesses. She said that housekeeping was responsible for checking the temperatures in resident refrigerators and going forward would be responsible for disposing of expired food items. During an interview on [DATE] at 01:14 p.m., the ADMIN said that he expected that his staff would routinely check the temperatures in resident refrigerators to prevent residents from getting sick. Record review of temperature logs for [DATE] indicated that the refrigerator in Resident #315's room had not had a temperature check for the months of April, May, or June. Record review of facility policy titled Storage and Handling of food from outside sources dated [DATE], indicated .The facility will record routine temperature logs and provide cleaning and sanitation as necessary .

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the stove was in working order. Two of the six burners on the stove did not light, when the knobs were turned. DM turned knobs on for the middle burners to light (they did not) and left gas on, when the burners on the right side of the stove lit the [NAME] shot across the top of the stove and lit the middle burners. This failure could place the residents at risk of a fire and not having safe operating equipment. Findings included: During an observation on 06/05/23 at 9:12 AM, the DM was turning the knobs to light the burners on the stove. The middle burners on the stove did not light when the knob was turned. The DM had her head down close to the burners looking under a pot on the stove to see if the burner lit. When she turned the knob and lit the burners on the left side of the stove, the flames shot across the top of the stove and lit the middle burners. During an interview on 06/06/23 at 2:45 PM, the DM said she had the maintenance supervisor check the stove and he cleaned out the tubes and the pilot lights were staying lit now. She said it was her responsibility to notify the maintenance supervisor if equipment in the kitchen was not operating properly. She said the maintenance supervisor had just checked the stove last week and it was working fine. She said she was not aware it was not working at time of survey. She said if the gas builds up it could cause a fire or for someone to get burned. A policy Title: Equipment Maintenance, not dated, indicated: 1. The maintenance director is responsible for ensuring the building, grounds and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 7 residents (Resident # 60) observed for care in that: CNA B failed to close the blinds and pull the privacy curtain during personal care for Resident #60. This failure could affect all residents in the facility who received care and could result in residents not being treated with dignity and respect and being exposed during care. Findings: Record review of facility face sheet dated 6/06/2023 indicated Resident # 60 admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (impaired breathing that causes low oxygen to the brain), severe sepsis (infection in the body), and urinary tract infection. An Admission MDS dated [DATE] indicated Resident #60 had a BIMS of 08 indicating moderate cognitive impairment and required extensive assistance with transfers, dressing, and toileting. A Care plan dated 05/04/2023 indicated a self-care deficit and required extensive assistance. During an observation on 06/05/23 at 10:12 AM CNA B provided personal care to Resident # 60 without closing the window blinds and pulling the privacy curtain. Resident # 60 was not interviewable and resided in a private room. During an interview on 06/05/23 at 10:41 AM CNA B stated she had been a CNA for 1 year and she should have pulled the privacy curtain and closed the window blinds before providing personal care to Resident # 60. She stated she had been trained on how to maintain resident privacy and dignity when she was hired, and it was her mistake for not doing it correctly. She stated the resident's dignity could be affected and she should have protected them. During an interview on 06/07/23 at 09:01 AM the IP nurse stated she oversees all staff training and education. She stated all nursing staff are trained on hire, annually and as needed regarding maintaining dignity. She stated blinds are to be closed and the curtain pulled anytime personal care is being provided. She stated the risk could be embarrassment. She stated she expects all staff to maintain residents' dignity and privacy and will start retraining. During an interview on 06/07/23 at 09:06 AM the DON stated IP oversees the staff training program. The DON stated she reviewed the trainings and reports. She stated all residents should be treated with dignity to avoid embarrassment and expects all staff to follow facility policy and procedures for maintaining dignity. During an interview on 06/07/23 at 1:09 PM the Admin stated everyone was responsible for ensuring resident privacy and dignity. He stated the resident could be affected psychosocially and make them uncomfortable if their dignity and privacy were not maintained. He stated his expectation going forward was that all residents are cared for with privacy and dignity. Record review of facility policy and procedure titled Resident Rights dated August 14, 2022, indicated' .the staff will abide by and protect resident rights in accordance with state and federal guidelines.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure all food items were labeled and dated in the freezer and two refrigerators. The facility failed to ensure Refrigerator #1 and Refrigerator #2 maintained a safe storage temperature. These failures could place residents at risk of foodborne illness. Findings included: Record review of a week 3 regular menu indicated for the evening meal on Monday black bean soup, egg salad sandwich, beet and onion salad, winter fruit cup, milk, iced tea and oil and vinegar dressing. The alternate was chef salad, garlic bread stick, salad dressing, milk whole, coffee, hot tea, hot chocolate and buttery spread. The breakfast menu for Tuesday morning indicated orange juice, oatmeal, French toast casserole, sausage patty, coffee, milk 1%, water, and syrup. The alternate breakfast menu indicated apple juice, cranberry juice, fruit loops, cheerios, cornflakes, raisin bran, cream of wheat, egg to order, bacon, sausage patty, Biscuit gravy, whole milk, hot tea, and jelly. Record review of a Refrigerator /Freezer Temperature Log dated April indicated Unit #3 (Refrigerator #2) on April 25 PM the refrigerator temperature was 55 degrees. The entry was initialed by the Dietary Supervisor. On April 26 AM the temperature for Unit #3 (Refrigerator #2) was 60 degrees. The entry was initialed by the Dietary Supervisor. During an observation on 4/25/22 at 9:18 a.m., revealed in the small chest type cooler in the kitchen there were two glasses with thick white liquid labeled BM with no date and 4 small round plastic to-go containers with lids with thick white substance sitting on a tray with no date or label. During an interview and observation on 4/25/22 at 9:12 a.m., revealed in refrigerator #1 in the pantry 2 clear plastic bags with yellow cornbread with no date or label. There was a plastic bag opened to air with an unknown cooked meat inside with no date or label. There was a metal container covered in foil labeled Red beans with no date. There was a metal container covered in foil with an unknown cooked green vegetable inside with no date or label. The dietary supervisor said the refrigerators were cleaned out twice a week. She said she checks the refrigerators on Mondays and throws out anything that does not have a date on it. She said there was a substitute cook working over the weekend and they may not have known to date or label the food. She said the full-time staff does know they were supposed to date and label food. During an observation on 4/25/22 at 9:27 a.m., revealed in refrigerator #2 inside the pantry a tray with beverages (4 glasses with a clear liquid, 2 glasses with an amber liquid, 1 glass with an orange liquid, and 1 glass with a red liquid), with no date or label. There was 1 plastic zip bag with grated cheese, sliced cheese, and lunch meat inside with no date or label. There were cheese slices wrapped in plastic wrap with no date or label. There was a plastic zip bag with an unknown meat salad with no date or label. There was a tray with 25 small round plastic to-go contains with lids with a thick red substance in each sitting on a tray with no date or label. During an observation on 4/25/22 9:33 a.m., revealed in the freezer a plastic zip bag with brown frozen sticks of an unknown food item with no date or labels. There were 2 white bowls covered in plastic wrap with a frozen orange substance with no date or label. There were 3 pints of ice cream in a black plastic shopping bag with no date. There was a box labeled cheese pizza with 3 plastic bags of frozen unknown meat inside the box with no date or label. There was 1 gallon of Vanilla ice cream with no received date. There were 2 packages of unknown meat with no date of label. During an observation on 4/25/22 at 9:40 a.m., revealed 5 trays of glasses filled with an amber liquid and a clear liquid sitting next to the sink with no date or labels. During an interview and observation on 04/25/22 at 10:05 a.m., revealed refrigerator #1 the outside thermometer read 51 degrees and refrigerator #2 read 61 degrees . Refrigerator #1 contained a clear plastic bags with yellow cornbread with no date or label. There was a plastic bag opened to air with an unknown cooked meat inside with no date or label. There was a metal container covered in foil labeled Red beans with no date. There was a metal container covered in foil with an unknown cooked green vegetable inside with no date or label. , eggs, lettuce, and tomatos. Refrigerator #2 contained condiments, pickles, sliced cheese, grated cheese, lunchmeat pudding, an unknown fruit, an unknown green vegetable, 2 containers of sour cream, a box with 6 bags of sour cream and a container of cottage cheese. Both were checked with the thermometers on the outside of the refrigerators. Cook E said the refrigerators were not cooling like they should. She said fridge #1 had quit working 3 months ago and had to be worked on. She said she did not know when it had quit cooling again. She said it began leaking water on 4/24/22. The floor was wet near refrigerator #1. During an interview on 4/25/22 at 10:15 a.m., the Dietary Supervisor revealed the refrigerator temperatures were checked 3 times a day. She said the higher temperatures had not been reported to anyone because the temperature was normal when it had been checked earlier in the morning. She did not give a time the temperatures were checked. She said she had issues off and on with the refrigerators. She agreed both refrigerators were not cooling properly . She said the Maintenance Supervisor had been working on them and replaced a seal on refrigerator #1. During an observation on 4/25/22 at 11:25 a.m., the external thermometer on refrigerator #1 read the temperature at 52 degrees. The external thermometer on refrigerator #2 read 60.8 degrees. During an observation on 4/25/22 at 2:11 p.m., the external thermometer on refrigerator #1 read the temperature at 46 degrees. The external thermometer on refrigerator #2 read 59 degrees. During an interview on 4/25/22 at 2:13 p.m., the Maintenance Supervisor revealed there was a temperature log on all of the refrigerators. He said no one had reported to him any issues with refrigerators today. He said he had not seen a request for refrigerator repair in repair request logbook. During an observation on 4/25/22 at 2:15 p.m., revealed a black notebook at the nurse's station labeled for repair request from Maintenance. There was not a request for refrigerator repair. The last entry was 4/25/2022 for repair in the front bathroom. During an interview on 04/25/22 at 02:16 p.m., the Dietary Supervisor revealed she had reported the issue with the refrigerators not cooling properly to the maintenance supervisor on the morning of 4/25/2022. She said she reported the issue to him when he came in her office this morning. She said she was working on removing the food. She said no food would be served out of the refrigerators and most of the evening meal would come out of the freezer. She said they were working on renting a refrigerator. During an interview on 4/25/2022 at 3:45 p.m., the Maintenance Supervisor said the temperatures were too high in refrigerator #1 and refrigerator #2 when he had checked them. He said he had turned them both down and refrigerator #1 was now down to 45 degrees. During an observation on 04/26/22 at 8:20 a.m., Refrigerator #1 was at 45 degrees on a thermometer on the inside of the refrigerator and refrigerator #2 was at 59 degrees based on the external thermometer. Refrigerator #1 contained 1 full box of eggs and a partial box of eggs, lettuce, and tomato. Refrigerator #2 contained yellow mustard, ketchup, unknown fruit in a pitcher, 2 cartons of sour cream, 1 cottage cheese, pickles, 1 pudding, butter, unknown thick red substance with no label, jalapeno peppers, a box of broccoli, 2 bags containing chopped vegetables, and a box containing 6 bags of sour cream. During an interview on 4/26/2022 at 8:57 a.m., the Dietary Supervisor said the only thing served out of either of the refrigerators were the eggs used for egg salad sandwiches for dinner on 4/25/2022 and eggs were used for breakfast the morning the morning of 4/26/2022. During an interview on 04/27/22 at 09:00 a.m., Cook F revealed she was unaware of any cooling problems with the refrigerators. She said she does not check the temperatures on the refrigerators. She said the cook on the evening shift was the one that checks the temperatures. She said there was no log to record the refrigerator temperatures and if there was one she was not sure where it was kept. During an interview on 04/27/22 at 09:10 a.m., the Dietary Supervisor revealed on the morning of 4/25/2022 when she became aware of the high temperatures in the refrigerators, she mentioned it in passing to the maintenance supervisor. She said she could not find the repair request logbook. She said the process for reporting repair request was to tell the maintenance supervisor, the administrator and enter the request into a repair request logbook. She said no food was removed after she became aware of the issue and the eggs were still served for the evening meal and the next morning for breakfast. She agreed the refrigerators were at an unsafe temp for at least 4 hours on Monday. She said it was the cooks' job to check the refrigerator temperatures and put the temperatures on the log 3 times a day. She said the temperature log was kept in a notebook in the kitchen. She did not give an exact time for the temperatures to be recorded each day. She said if a food was stored at an unsafe temperature, it depends on what the food item was if it could possibly make residents sick or not. She said undated food could make residents sick because if it was undated you don't know how long it has been in the refrigerator. She said if any staff puts food in a refrigerator or freezer the food should be dated and labeled as it is being put in the fridge. She said she checks the refrigerators several times a week for undated and unlabeled food. She said anything undated or unlabeled is thrown away. She said she especially checks on Mondays for undated or unlabeled food because she had been off two days. During an interview on 4/27/22 at 01:41 PM, the Administrator revealed on 4/25/2022 the Dietary Supervisor came directly to him to notify him of the refrigerators not working properly. He said Corporate Maintenance was present. He said he immediately started making calls and had difficulty finding someone to come in to repair the refrigerators. He wanted someone to come in from directly from the outside to repair the refrigerator and not have the Maintenance Supervisor work on them. He said the facility has limited resources. He said he felt the eggs were still safe to eat. He said eggs can be at a certain temperature and still be ok. He said the Dietary Supervisor has documentation on this . He said when the Dietary Supervisor left at 7 pm on 4/25/2022, the temperature for refrigerator #1 was 40 degrees. On 4/27/2022 at 1:45 p.m., the egg safety documentation was requested from the Administrator and was not received prior to exit. Review of a facility Hot and Cold Food Temperatures policy dated August 1, 2008 indicated, .The temperatures of the food items will be managed to conserve maximum nutritive value and flavor and to be free of harmful organisms and substances . Review of a facility Food Storage policy dated August 1, 2018 indicated, .Sufficient storage facilities are provided to keep foods safe .food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination .Refrigerator: .temperatures are at or below 40 degrees Fahrenheit .all foods are covered, labeled, and dated .Freezer: .all foods are covered, labeled, and dated . Review of an article published by the Food and Drug Administration What you need to know about egg safety, https://www.fda.gov/food/buy-store-serve-safe-food/what-you-need-know-about-egg-safety, dated March 2021 indicated, .Fresh eggs, even those with clean, uncracked shells, may contain bacteria called Salmonella that can cause foodborne illness, often called food poisoning .Certain people are at greater risk for severe illness and include children, older adults .Safe Handling Instructions to prevent illness from bacteria: keep eggs refrigerated .store promptly in a clean refrigerator at a temperature of 40 degrees F or below .

Based on observation, interview and record review the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. The facility failed to ensure Refrigerator #1 and Refrigerator #2 maintained a safe storage temperature. This failure poses a risk of essential kitchen equipment malfunctions causing foods to be held at an unsafe temperature and cause food borne illness. Findings included: Record review of a Refrigerator /Freezer Temperature Log dated April indicated Unit #3 (Refrigerator #2) on April 25 PM the refrigerator temperature was 55 degrees. The entry was initialed by the Dietary Supervisor. On April 26 AM the temperature for Unit #3 (Refrigerator #2) was 60 degrees. The entry was initialed by the Dietary Supervisor. During an interview and observation on 04/25/22 at 10:05 a.m., revealed refrigerator #1 the outside thermometer read 51 degrees and refrigerator #2 read 61 degrees. Both were checked with the thermometers on the outside of the refrigerators. Cook E said the refrigerators were not cooling like they should. She said fridge #1 had quit working 3 months ago and had to be worked on. She said she did not know when it had quit cooling again. She said it began leaking water on 4/24/22. The floor was wet near refrigerator #1. During an interview on 4/25/22 at 10:15 a.m., the Dietary Supervisor revealed the refrigerator temperatures were checked 3 times a day. She said the higher temperatures had not been reported to anyone because the temperature was normal when it had been checked earlier in the morning. She did not give a time the temperatures were checked. She said she had issues off and on with the refrigerators. She agreed both refrigerators were not cooling properly. She said the Maintenance Supervisor had been working on them and had replaced a seal on refrigerator #1. During an observation on 4/25/22 at 11:25 a.m., the external thermometer on refrigerator #1 read the temperature at 52 degrees. The external thermometer on refrigerator #2 read 60.8 degrees. During an observation on 4/25/22 at 2:11 p.m., the external thermometer on refrigerator #1 read the temperature at 46 degrees. The external thermometer on refrigerator #2 read 59 degrees. During an interview on 4/25/22 at 2:13 p.m., the Maintenance Supervisor revealed there was a temperature log on all of the refrigerators. He said no one had reported to him any issues with refrigerators today. He said he had not seen a request for refrigerator repair in repair request logbook. During an observation on 4/25/22 at 2:15 p.m., revealed a black notebook at the nurse's station labeled for repair request from Maintenance. There was not a request for refrigerator repair. The last entry was 4/25/2022 for repair in the front bathroom. During an interview on 04/25/22 at 02:16 p.m., the Dietary Supervisor revealed she had reported the issue with the refrigerators not cooling properly to the maintenance supervisor on the morning of 4/25/2022. She said she reported the issue to him when he came in her office that morning. During an interview on 4/25/2022 at 3:45 p.m., the Maintenance Supervisor said the temperatures were too high in refrigerator #1 and refrigerator #2 when he had checked them. He said he had turned them both down and refrigerator #1 was now down to 45 degrees. During an observation on 04/26/22 at 8:20 a.m., Refrigerator #1 was at 45 degrees on a thermometer on the inside of the refrigerator and refrigerator #2 was at 59 degrees based on the external thermometer. Refrigerator #1 contained 1 full box of eggs and a partial box of eggs, lettuce, and tomato. Refrigerator #2 contained yellow mustard, ketchup, unknown fruit in a pitcher, 2 cartons of sour cream, 1 cottage cheese, pickles, 1 pudding, butter, unknown thick red substance with no label, jalapeno peppers, a box of broccoli, 2 bags containing chopped vegetables, and a box containing 6 bags of sour cream. During an interview on 04/27/22 at 09:00 a.m., Cook F revealed she was unaware of any cooling problems with the refrigerators. She said she does not check the temperatures on the refrigerators. She said the cook on the evening shift was the one that checks the temperatures. She said there was no log to record the refrigerator temperatures and if there was one she is not sure where it was kept. During an interview on 04/27/22 at 09:10 a.m., the Dietary Supervisor revealed on the morning of 4/25/2022 when she became aware of the high temperatures in the refrigerators, she mentioned it in passing to the maintenance supervisor. She said she could not find the repair request logbook. She said the process for reporting repair request was to tell the maintenance supervisor, the administrator and enter the request into a repair request logbook. She said no food was removed after she became aware of the issue and the eggs were still served for the evening meal and the next morning for breakfast. She agreed the refrigerators were at an unsafe temp for at least 4 hours on Monday. She said it was the cooks' job to check the refrigerator temperatures and put the temperatures on the log 3 times a day. She said the temperature log was kept in a notebook in the kitchen . She did not give an exact time for the temperatures to be recorded each day. She said if a food was stored at an unsafe temperature, it depends on what the food item is if it could possibly make residents sick or not. During an interview on 4/27/22 at 01:41 PM, the Administrator revealed on 4/25/2022 the Dietary Supervisor came directly to him to notify him of the refrigerators not working properly . He said Corporate Maintenance was present. He said he immediately started making calls and had difficulty finding someone to come in to repair the refrigerators. He wanted someone to come in from directly from the outside to repair the refrigerator and not have the Maintenance Supervisor work on them. He said the facility has limited resources. He said he felt the eggs were still safe to eat. He said eggs can be at a certain temperature and still be ok. He said the Dietary Supervisor has documentation on this. He said when the Dietary Supervisor left at 7 pm on 4/25/2022, the temperature for refrigerator #1 was 40 degrees. The Administrator said the only policy available was concerning the dish washer and the ice machine. He said there was no policy available for the refrigerators. On 4/27/2022 at 1:45 p.m., a refrigerator policy was requested from the Dietary Supervisor and the Administrator on 4/27/2022. The Administrator said there was not one available.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 19 residents reviewed for resident rights. (Resident #13, Resident # 28, and Resident #31) The facility did not ensure Resident #13, Resident #28, or Resident #31 were assisted with eating their lunch meal in a dignified manner. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings included: 1.Record review of Face Sheet dated 4/27/22 indicated Resident #13 was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of most recent MDS dated [DATE] indicated Resident #13 usually made himself understood, and usually understood others, and had severe cognitive impairment with BIMS of 07. The MDS indicated Resident #13 required limited assistance with ADL's. Record review of care plan dated 2/27/22 indicated Resident #13 had an altered nutritional status and had a need for assistance/cueing with meals. It indicated he would receive necessary assistance with food and fluids over the next 90 days. The intervention was to provide assistance with food and fluids. During an observation on 04/25/22 12:12 PM CNA G stood beside Resident #13 who was seated in a chair in front of the table and tried to give him a bite of food, and he shook his head and refused. 2.Record review of Face Sheet dated 4/27/22 indicated Resident #28 was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] indicated Resident #28 was able to make herself sometimes understood, sometimes understood others and had severe cognitive impairment with a BIMS summary score of 0. The MDS indicated Resident #28 required extensive assistance with eating. Record review of the care plan dated 4/15/22 indicated Resident #28 had an altered nutritional status and had a need for assistance due to dysphagia and chewing difficulties/cueing with meals. It indicated she would receive necessary assistance with food and fluids over the next 90 days. The intervention was to monitor oral intake of food and fluid. During an observation on 04/25/22 at 12:05 PM ADON stood over Resident #28 while she was in her wheelchair encouraging her to eat and gave her a bite while standing over her. During an observation on 04/25/22 at 12:07 PM ADON walked back by encouraging Resident #28 to eat a bite and gave her a bite while standing over her. During an observation on 04/25/22 at 12:09 PM ADON walked back over to Resident #28 encouraging her to eat and gave her a bite standing up beside her. 3.Record review of Face Sheet dated 4/27/22 indicated Resident #31 was [AGE] years old and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS dated [DATE] indicated Resident #31 was able to make herself understood, usually understood others and had moderate cognitive impairment with a BIMS summary score of 11. The MDS indicated Resident #31 required supervision with eating. Record review of the care plan dated 4/15/22 indicated Resident #31 had an altered nutritional status and had a need for assistance/cueing with meals. It indicated she would receive necessary assistance with food and fluids over the next 90 days. The intervention was to monitor oral intake of food and fluid. During an observation and interview on 04/25/22 at 12:33 PM CNA J stood over Resident #31 feeding her in her room. Resident #31 was in her wheelchair and food was on the bedside table. CNA J stood beside Resident #31 feeding her directly in front of her roommate who was seated in a chair feeding herself. CNA J said that she was feeding Resident #31 while she stood. During an interview on 04/27/22 at 9:15 AM with CNA J, said staff were trained on the appropriate way to assist a resident with eating. She said while assisting Resident #31, she should have sat in a chair to assist her. She said staff should sit while assisting so Residents don't feel like you are in a hurry to assist. CNA J said she stood to feed Resident #31 because there was not enough space to put a chair to sit in. During an interview on 04/27/22 at 10:38 AM with CNA G, she said staff should sit beside a resident when helping them eat. She said staff should never stand so that staff have the right angle and not put too much food in their mouth. She said staff should not stand because it would make residents feel like they were being forced and she (CNA G) wouldn't like somebody standing over her. She said if staff sit down and talk to a resident they may eat more. CNA G said she should not have stood beside Resident #13 and gave him a bite. She said staff were trained on the appropriate way to assist a resident with eating. CNA G said she was standing when she gave him a bite, because she was just trying to get him to eat a little more. During an interview on 04/27/22 at 10:15 AM with ADON, she said staff were supposed to sit down while assisting a resident with eating. She said some with dementia have to be encouraged to eat more and sometimes if you talk to them a little bit they will eat more. She said that she should have sat down when she was assisting Resident #28 with eating. She said you should be at eye level when you are assisting a resident. ADON said you are at eye level so they can see you and you are not standing over them putting food in their mouth. She said staff were trained on how to assist a resident with eating. ADON said CNA's were trained to sit to assist a resident with eating. She said if she saw a staff feeding a resident standing, she would redirect them to sit. ADON said she did not see CNA G standing over Resident #13, but if she did, she would have redirected her to sit had she seen it. ADON said she stood because she was trying to assist multiple residents with their needs. During an interview on 04/27/22 at 11:37 AM with DON said staff were supposed to sit down when feeding a resident and staff should be eye level or below and this was done so they feel equal to you. DON said residents were not as comfortable if staff were standing up. DON said staff had received training on proper way to assist a resident with eating and they were re-in-servicing right now. During an interview on 04/27/22 01:43 PM with Administrator, he said he would expect a staff to be seated in most instances when assisting a residence with feeding. Administrator said he would expect staff to do whatever promotes the most dignity for a specific resident regarding whether they were sitting or standing while feeding. Administrator said with Resident #31 staff should have been sitting. Administrator said with Resident #13 he can feed himself and understand more and there were times that his abilities fail. Administrator said verbal cues were okay standing with Resident #13, but if they were assisting with eating staff would need to be seated. Administrator said he would expect staff to be seated while feeding Resident #28. Administrator said staff were trained to be seated at eye level while feeding a resident. Administrator said a staff being seated was a safety and dignity issue. Administrator said for example if a resident choked a staff would need to be seated so they would know that a resident was having an issue. An undated Statement of Resident Rights policy indicated, If anyone hurts you, threatens you, neglect your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Human Services by calling [PHONE NUMBER] you have a right to be treated with courtesy, consideration and respect . Review of a Policy dated 2/12/20 Assisting Residents with eating indicated, Qualified nursing staff will assist the resident who is unable to feed self in order to promote adequate nutrition and to help the resident enjoy a satisfying meal .sit down if possible .

Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source are reported immediately or not later than 24 hours for 1 of 19 residents reviewed for abuse and neglect. (Resident #36) Resident #36 sustained an injury of unknown source that was not reported timely as required. This failure could place residents at risk for abuse and neglect. Findings included: Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #36 was rarely/never understood and rarely/never understood others. A BIMS (Brief Interview for Mental Status) was not conducted due to Resident #36 being rarely to never understood. The MDS indicated Resident #36 required extensive assistance with ADLs. Record review of a care plan dated 3/2/22 indicated Resident #36 had a cognitive deficit. The care plan indicated the resident missed intent/part of messages at times and had trouble expressing self at times. Record review of nurse's note in the electronic chart for Resident #36 dated 3/18/2022 at 11:22 AM revealed, CNA A reports that while getting resident up and dressed, she noticed bruise to the left eye and notified the nurse. Bruise is 3x1 on upper eyelid. Resident was observed by this nurse rubbing both eyes several times, upon further investigation, noted bruising to left side of forehead above eye measuring 2x1. It appears resident bumped her head against something, possibly the wall that her bed is against, and bruising went down into eyelid. She appears unafraid. She is alert and confused, as is her norm. Family member notified, who stated that resident keeps a bowl of snacks by her bed and could have bumped her head against that table while getting a snack. Will be getting witness statement from 10-6 shift. Will monitor area until resolved. MD notified with n/o (new order) for CBC. DON notified. Neuros started. The note was signed by LVN B. Record review of the facility's Incident/Accident Report dated 3/18/2022 for Resident #36 revealed, .Type of Incident - Bruise/discoloration - left eyelid, left forehead .Witnesses - No .Injury Report - Type of Injury - Bruise/discoloration .Description of Incident - 6-2 CNA A noted bruise to resident's left eye when she was getting her up and dressed. Notified LVN C. Resident was observed rubbing her eyes several times but does not have the cognitive ability to tell us how she obtained the bruise. Upon further inspection noted bruise to left side of forehead just above eye. It appears she bumped head and bruising to eye is result of that . The incident report was electronically signed by the DON and the Administrator. The incident report was completed by the Administrator on 3/31/2022 at 3:14 PM. Record review of a Witness Statement by NCNA (Non Certified Nurse's Aide) H, dated 3/18/2022 revealed, .Date of Accident/Incident 3/17/2022 .When I came in March 17, 22 to work A Hall doing my first round, I noticed a bruise on Resident #36's left eye . The witness statement was signed by NCNA H. During an interview on 04/26/22 at 3:52 p.m., LVN C revealed she was the one that assessed Resident #36 on 3/18/2022. She said the bruising was on her forehead just above her left eye and went down onto her left eye. She said because the resident's cognition ability she was unable to say what happened to her eye. LVN C said she notified the DON. During an attempted interview on 4/27/22 at 8:30 a.m., revealed Resident #36 was unable to answer questions concerning the incident from 3/18/2022. During an interview on 4/27/22 at 8:52 a.m., the DON revealed the injury to the face of Resident #36 on 3/18/2022 was not reported to the state because of her [CONDITION(S)]. She said the resident was unable to communicate what happened to her eye. She said the injury consisted of a bump on her forehead a small area of a purple discolored are to her eyelid. She said the injury was not a bruise. She said she did not report this injury because she was pretty sure of what happened. She felt the injury was not unknown even though the resident cannot verbalize what happened. She said a family member had suggested that maybe Resident #36 had bumped her eye. She said she believed this to be true because of the resident's history. She said the resident had bruising to her arm previously from a blood pressure cuff. She said she did not know at the time that the injury on 3/18/22 was considered an injury of unknown origin. The DON did agree an injury of the face was a suspicious injury. She said the Administrator was the Abuse Coordinator. During an interview on 4/27/22 at 1:41 a.m. The Administrator revealed he was notified of the injury to the left eye by a family member of Resident #36. He said he was unsure of the date the family member reported the injury to him. He said he did not report the injury to the state because the family member told him they were not concerned about the injury. He said, We do not have a ton of self-reports and the family member wanted me to know that she wasn't concerned. He said he did not attempt to interview Resident #36 because she was non-interviewable and the family member was her legal advocate. He said normally this type of injury would be concerning to him but since the family member said they were not worried about it, he did not feel it needed to be reported. He said injuries of unknown origin should be reported within 24 hours. Review of a facility Abuse Prohibition Management Program - Screening, Training, and Prevention Policy dated 9/1/2005 indicated, .When an alleged or suspected case of mistreatment,, neglect, injuries of unknown source, or abuse is reported the facility administrator, or his/her designee, will notify the following persons or agencies of such incident; the State licensing/certification agency responsible for surveying/licensing the facility .The facility's Administrator, and in his/her absence, the Director of nursing will perform the duties of the Abuse Prevention Coordinator. Duties include .assuring that the timely identification, investigation, and report of incidences .the Abuse Prevention Coordinator will immediately report to the State Agency and other appropriate authorities, incidents of resident abuse as required under applicable regulations and regulatory guidance .

Based on interview and record review, the facility failed to thoroughly investigate and report injuries of unknown origin for 4 of 14 residents reviewed for abuse and/or neglect. (Resident #s 72, 5, 10, and 56) IMMEDIATE JEOPARDY 1. Resident #72 was admitted after breaking his arm during a fall. He sustained two falls after admission and the facility did not make further updates to his plan of care. Resident #72 fell a third time in his room and lost consciousness. The facility did not respond to his bed or personal alarms for an unknown period of time. LVN A heard the alarms and found Resident #72 face down on the floor of his room with a contusion on his forehead and bleeding from his arm. He was sent to the hospital and was diagnosed with [REDACTED]. The facility did not thoroughly investigate or report the incident. 2. Resident #5 was readmitted after breaking her hip during a fall. She sustained 20 falls between 01/02/14 and 04/21/14. The facility did not revise or implement interventions following those falls. The facility did not thoroughly investigate the incidents. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. This failure could place 54 residents who were at risk for falls, 21 of those had alarms, at risk for serious injury or death in the event of a fall. NON-IMMEDIATE JEOPARDY 3. Resident #10 sustained a first degree burn. The facility did not conduct a thorough investigation of the incident. 4. Resident #56 obtained a spiral fracture to the left distal fibula. The facility found out about an incident in the shower which occurred with CNA S. The facility did not thoroughly investigate the incident. Resident #56 also had scratches to her right leg. The facility did not thoroughly investigate the incident. This failure could place 23 residents with incidents in March 2014 at risk of abuse and/or neglect. Findings included: IMMEDIATE JEOPARDY 1. Undated physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and [MEDICATION NAME] 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An admission MDS dated [DATE] indicated Resident #72 had moderately impaired cognition, physical and verbal behaviors, required extensive assistance of two persons to transfer, did not walk, had a fall with fracture prior to admission, and had 1 fall with no injury since admission. A fall risk care plan dated 01/09/14 indicated Resident #72 was at risk for falls due to increased weakness and decrease in cognition. The goal was for the resident to have no falls for 90 days. Interventions were: "Gather and assess information on past falls; monitor and document signs/symptoms of adverse effects of medications; encourage to request assist in ambulating; clutter-free environment and articles of care within resident's reach; refer to therapy for evaluation as indicated for any (signs/symptoms) of decline; keep call light in reach and answer promptly; assist with transfers and ambulation as needed; and encourage resident to call for assistance as needed and report any signs of dizziness." A personal alarm care plan dated 01/09/14 indicated Resident #72 required use of a personal alarm. The goal was for the resident to have the personal safety alarm attached for the next 90 days. Interventions included: "Resident will have personal alarm attached to self and chair when up in chair; resident will have personal alarm attached to self and bed when in bed; respond immediately to alarm when it goes off..." An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell ." A fall risk care plan dated 01/09/14 indicated a hand written notation dated 02/20/14 indicating Resident #72 had an actual fall on 02/20/14 "neuros started and are (within normal limits)." No new goals or interventions were noted. Behavior monitoring records dated March 2014 indicated Resident #72 had no behaviors documented and had no side effects from his quitiapine or [MEDICATION NAME]. An incident report completed by LVN A dated 03/12/14 indicted on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated there was "no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." During an interview on 04/26/14 at 9:35 a.m., LVN A said he came in around 9:00 p.m. or 9:15 p.m. to get ready for his shift. When he walked in the door, he heard an alarm going off. He said he did not see any staff at the nursing station or in the halls. He first went down Hall A, and the alarm was not on that hall. He then started down Hall B, and the alarm was going off in Resident #72's room, the first room on the right. He said Resident #72 was lying "face down and unconscious." He said there was blood on the floor. He said he checked for a pulse and respirations and called out for help. He said he saw a contusion above the resident's eye. LVN A said LVN B arrived and took the resident's vital signs. LVN A said he then left and called the doctor for an order to transfer Resident #72 to the hospital. LVN A said he did not write any nursing notes. He said, "I guess I thought (LVN B) would do the the nurses' notes." During an interview on 04/26/14 at 10:05 a.m., LVN A said he called the physician to notify him of what happened. He was not sure how long it was between calling the physician and the ambulance arriving. LVN A said Resident #72 was "face down in front of the bathroom door. It looked like he hit his head on the table or the refrigerator as he fell . He was contorted, had a contusion over his eye, and there was blood on his arm. He was breathing and had a pulse." LVN A could not remember if the resident had any socks or shoes on. LVN A further stated, "When (LVN B) came in, she took his vital signs. I don't remember seeing any staff in any of the hallways when I got to work." LVN A said prior to this incident, Resident #72 had to be carefully watched because he would try to get out of his geri chair all the time when he was awake. He said Resident #72 usually had a pad alarm and a clip alarm because he would pull his clip alarm off. LVN A said when the resident was restless, they would bring him to the nursing station in his geri chair so they could watch him. LVN A said the hospital said the cause of Resident #72's death was bruising on the brain related to this injury. LVN A said the normal staffing for the 2:00 p.m. to 10:00 p.m. shift was 3 nurses and 6 CNAs. A staff sign-in assignment record dated 03/11/14 indicated there were 3 LVNs and 5 CNAs. During an interview on 04/26/14 at 3:55 p.m., CNA C said she put Resident #72 to bed with both his pad (bed) alarm and clip on alarm. She was not sure of the time. CNA C said the bed was in the low position and the door was open. She said she took his dirty linens out then went to the room next door to Resident #72 to assist that resident to bed. She said she was in that resident's room with the door closed. CNA C said she did not hear the alarm in Resident #72's room. CNA C said the first she knew of the incident was when LVN A came to get her for assistance. CNA C said it could not have been more than 10 minutes between putting Resident #72 to bed and LVN A asking for assistance. CNA C said Resident #72 was on the floor by the bathroom door and there was blood on the floor. She said the resident was not talking. She said the resident "came alert" when LVN A asked, "Are you hurt?" CNA C said Resident #72 responded, "I got to get up." CNA C said another nurse came in, but she did not remember who the nurse was. CNA C said Resident #72 did not usually try to get out of bed. She said when the resident was agitated, they would put him in a geri chair at the nursing station. CNA C said when the resident was in bed, they "checked on him a lot" because he was active. CNA C said the ambulance arrived a few minutes before 10:00 p.m. During an observation on 04/26/14 at 4:05 p.m., a surveyor stood in Resident #72's room with the door open and a second surveyor went in the room next door with the door closed. The surveyor separately set off both a pad (bed) alarm and a personal clip alarm in the room that had been Resident #72's. Both could clearly be heard from the next room. At 4:10 p.m., a surveyor stood at the entrance door. Both alarms could clearly be heard when set off. During an interview on 04/26/14 at 4:15 p.m., the treatment nurse said the alarms were always kept on the high setting. The back of the alarms had to be removed to change the setting. She said it could "definitely" be heard if you were in the room next door where an alarm was sounding and could be heard "from one end of the hall to the other." During an interview on 04/26/14 at 4:39 p.m., LVN B said she worked prn (as needed). She said she was in the hall at the opposite end of Hall B from Resident #72's room. She said a CNA, who she could not identify, hollered from Resident #72's room to get some gloves and come quickly. LVN B said she did not hear an alarm. When she came in the room, LVN A was with the resident. The resident was face down on the floor with his arm under him. LVN B said LVN A lifted the resident and got his arm from beneath him. LVN B said she could then see Resident #72 was bleeding from his arm or his hand and had a bruise developing over his eye. She said she applied pressure to his bleeding arm. LVN B said she did not recall the resident saying anything, but he was making some "noises." LVN B said she took Resident #72's vital signs and stated she "could not recall doing a whole lot." She stated, "I was afraid to move him much." She said the time of the incident was between 9:30 p.m. and 9:45 p.m. because she was finishing her medication pass. LVN B said she stayed with Resident #72 while LVN A left to make phone calls to get the resident transported to the ER. LVN A was not sure what time the ambulance arrived. She said she did not document anything about the incident in the nursing notes. LVN B said she thought LVN A did because he was more familiar with the documentation. LVN B said they usually kept Resident #72 in a geri chair at the nursing station where they could watch him more closely. LVN B stated, "We did not dare put the resident to bed before he got sleepy." LVN B said Resident #72 was sleepy earlier than usual that day and they put him to bed. LVN B said she should clearly hear an alarm sounding if she was in the hall. During an interview on 04/26/14 at 4:56 p.m., LVN D said she was the Hall A charge nurse the night of the incident with Resident #72. LVN D said she frequently worked Hall B as well and was familiar with Resident #72. LVN D said if she was down Hall A or if TVs were on loud, she would not hear an alarm on Hall B. LVN D said Resident #72 was very restless and repeatedly tried to get out of his geri chair. She said to keep him safe, she often had to take him in his geri chair down the hall with her so he could see her and she could talk to him. LVN D said she and the CNAs would take turns taking him with them on the hall. She said at times he was so active he required one-on-one supervision. 2. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated active physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. Comprehensive Care Plan dated 02/21/14 for Resident #5 indicated the following: "Problem: "Resident at risk for falls related to history of falls, unsteadiness, weakness, [MEDICAL CONDITION], confusion, multiple meds, and other disease process." Goals: "Resident will be free of falls/injuries related to falls x 90 days." - Approaches: "Gather and assess information on past falls ...encourage to request assist in ambulating;...Refer to therapy;... Notify MD/Family of changes; ...Keep call light in reach and answer promptly." Handwritten updates under the "problems" column of the care plan indicated resident #5 had falls on 02/22/14, 02/26/14, 04/04/14 and 04/16/14 with no injuries. Handwritten updates under the "goals" column of the care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to the back of the head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 cm (centimeter) abrasion above left eyebrow and on 04/09/14, she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. Resident #5's physical therapy "Resident Screening Form" dated 01/09/14 indicated the resident shows no change. Resident #5's therapy "Resident Screening Form" dated 02/07/14 indicated physical therapy was to evaluate and treat. Resident #5's therapy "Resident Screening Form" dated 03/10/14 indicated the resident was receiving physical therapy. Resident #5's "Therapy Screen" dated 04/16/14 and 04/21/14 indicated the resident showed no changes in abilities. Resident #5 was observed on 04/22/14 at 9:00 a.m., 04/23/14 at 9:20 a.m. and again at 9:35 a.m. in her wheelchair with the chair alarm attached. She was observed on 04/24/14 at 1:10 p.m. at the nurse's station and on 4/26/14 at 3:00 p.m. in the dining room playing bingo with the chair alarm attached. Staff was present each instance. During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. The ADON said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. The undated policy titled Abuse Prohibition Management Program indicated, "Our Facility will not condone resident abuse, neglect, or mistreatment... Prevention: 5. ...e. The assessment care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents...who require heavy nursing care and/or are totally dependent on staff...Procedures: Identification: 1. h. Neglect is...a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 a.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents' EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Condition form in addition to an Incident Report for every resident fall within one hour of fall. The Change of Condition Form prompts and documents comprehensive assessment of resident's condition and communication to the attending physician of the situation, background and assessment/appearance within 24 hours. 2. Charge nurses will be in-serviced on Change of Condition/Fall documentation prior to next shift by management nurses beginning 4/26/14. 3. DON/Administrator will review each incident report to ensure that an appropriate Change of Condition was completed and that the physician was notified timely of the resident's assessment/appearance and condition within 24 hours. Nurses found not to be in compliance will receive written counseling up to and including termination or further education as appropriate. 4. The DON and/or Administrator will be notified of any falls resulting in transfer to a hospital setting within 30 minutes. 5. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. 6. The QA/PI Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs were interviewed and were able to identify the risk factors that could lead to falls, ways to keep the environment safe, ways to assist residents who were at risk for falls, monitor residents who had a fall, and ways to prevent further falls should one occur, and how to monitor alarms were in place as ordered. Five LVNs and one RN were interviewed and were able to identify what documentation to do should a resident have a fall, who to notify, when to update care plans, when a fall risk assessment should be completed and within what time-frame, and when and how to initiate an investigation if a resident experienced a fall, and how to monitor that alarms were in place correctly. Fall risk assessments for 7 residents at high risk for falls were reviewed and the assessments had been updated as of 04/26/14. Care plans for 7 residents at high risk for falls were reviewed and the care plans had been updated as of 04/26/14. On 04/27/14 at 3:52 p.m., the administrator, corporate RN, and ADON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. NON-IMMEDIATE JEOPARDY 2. Undated active physician orders [REDACTED].#10 was a [AGE] year old female admitted on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #10's cognition was impaired. She required extensive assistance of two persons with eating. An Incident/Accident Report dated 03/21/14 for Resident #10 indicated..."2 x 2 cm (centimeter) blister noted to top of rt (right) breast area looks like burn..." During an interview on 04/22/14 at 11:27 a.m., the ADON said an incident report was completed but no investigation was done. During an interview on 04/22/14 at 11:35 a.m., Treatment Nurse said Resident #10 said she spilled coffee on herself. The Treatment Nurse said Resident #10 had a small fluid filled blister on her right breast that looked like a burn. During an interview on 04/22/14 at 5:12 p.m., the Administrator said an incident report was completed but nothing else was done to investigate the incident. During an interview on 04/23/14 at 8:42 a.m., CNA G said she had given Resident #10 coffee the day of the incident. CNA G said when she returned she noticed Resident #10 had a spill on her right side. CNA G said when she pulled the resident back she saw coffee and her cup on the floor. CNA G said no one was in the dining room with Resident #10 but she told the Treatment Nurse Resident #10 had spilled coffee on herself. CNA G said there was no redness but the next day the she observed a blister. An Abuse Prohibition Management Program policy revised 09/01/05 noted, "...Investigating: ...Should an allegation of suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident ...The individual con

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prevent neglect for 4 of 14 residents reviewed for neglect. (Resident #s 72, 5, 10, and 56) IMMEDIATE JEOPARDY 1. Resident #72 was admitted after breaking his arm during a fall. He sustained two falls after admission and the facility did not make further updates to his plan of care. Resident #72 fell a third time in his room and lost consciousness. The facility did not respond to his bed or personal alarms for an unknown period of time. LVN A heard the alarms and found Resident #72 face down on the floor of his room with a contusion on his forehead and bleeding from his arm. He was sent to the hospital and was diagnosed with [REDACTED]. 2. Resident #5 was readmitted after breaking her hip during a fall. She sustained 20 falls between 01/02/14 and 04/21/14. The facility did not revise or implement interventions following those falls. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. This failure could place 54 residents who were at risk for falls, 21 of whom had alarms, at risk for serious injury or death in the event of a fall. NON-IMMEDIATE JEOPARDY 3. Resident #10 sustained a first degree burn. The facility did not conduct an thorough investigation of the incident. 4. Resident #56 obtained a spiral fracture to the left distal fibula. The facility found out about an incident in the shower which occurred with CNA S. The facility did not thoroughly investigate the incident nor did the facility conduct a safe survey in a timely manner. Resident #56 also had scratches to her right leg. The facility did not thoroughly investigate the incident. This failure could place 23 residents with incidents in March 2014 at risk of abuse and/or neglect. Findings included: IMMEDIATE JEOPARDY The undated policy titled Abuse Prohibition Management Program indicated, "Our Facility will not condone resident abuse, neglect, or mistreatment... Prevention: 5. ...e. The assessment care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents...who require heavy nursing care and/or are totally dependent on staff...Procedures: Identification: 1. h. Neglect is...a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." An Abuse Prohibition Management Program policy revised 09/01/05 noted, "...Investigating: ...Should an allegation of suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident...The individual conducting the investigation will, at a minimum (and as appropriate): c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; j. Review all events leading up to the alleged incident; and l. Have all witnesses that are able to write a handwritten statement detailing their account of the incident...Witness statements should be handwritten by the witness, signed, and dated..." A Falls and Fall Risk, Managing Policy and Procedure revised December 2007 indicated the following: "Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify apprpriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If inderlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions...to try to minimize serous consequences of fallilng. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling... 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions... 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls." An accidents and incidents - investigating and reporting policy and procedure revised December 2007 indicated "All accidents or incidents involving residents ... occurring on our premises shall be investigated... 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the report of incident/accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness...; c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident;... i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (...transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required..." An undated Abuse Prohibition Management Program - Screening, Training, & Prevention policy indicated: "1. The facility's administrator, and in his/her absence, the (DON), will perform the duties of the Abuse Prevention Coordinator. Duties include, but are not limited to: ...b. Assuring appropriate... ongoing training of employees... in regards to the facility's Abuse Prohibition Management Program; ...d. Assuring that the timely identification, investigation and reporting of incidences of abuse occur... Investigating: 3. Should an allegation of suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Abuse Coordinator or his/her designee will investigate the alleged incident... 5. The individual conducting the investigation will, at a minimum (and as appropriate): ...d. Interview any witnesses to the incident; ...g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident: h. Interview the resident's roommate... l. Have all witnesses that are able to write a handwritten statement detailing their account of the accident... 26. (a.) Once an investigation has been conducted the social worker will conduct a 'Safe Survey.' The Social Worker will interview all other cognitive residents possibly affected by this incident. (b.) This action is to evaluate their perspective or their feeling of being safe and if they are aware of how to report an incident." 1. Undated physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and [MEDICATION NAME] 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An admission MDS dated [DATE] indicated Resident #72 had moderately impaired cognition, physical and verbal behaviors, required extensive assistance of two persons to transfer, did not walk, had a fall with fracture prior to admission, and had 1 fall with no injury since admission. A fall risk care plan dated 01/09/14 indicated Resident #72 was at risk for falls due to increased weakness and decrease in cognition. The goal was for the resident to have no falls for 90 days. Interventions were: "Gather and assess information on past falls; monitor and document signs/symptoms of adverse effects of medications; encourage to request assist in ambulating; clutter-free environment and articles of care within resident's reach; refer to therapy for evaluation as indicated for any (signs/symptoms) of decline; keep call light in reach and answer promptly; assist with transfers and ambulation as needed; and encourage resident to call for assistance as needed and report any signs of dizziness." A personal alarm care plan dated 01/09/14 indicated Resident #72 required use of a personal alarm. The goal was for the resident to have the personal safety alarm attached for the next 90 days. Interventions included: "Resident will have personal alarm attached to self and chair when up in chair; resident will have personal alarm attached to self and bed when in bed; respond immediately to alarm when it goes off..." An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell ." A fall risk care plan dated 01/09/14 indicated a hand written notation dated 02/20/14 indicating Resident #72 had an actual fall on 02/20/14 "neuros started and are (within normal limits)." No new goals or interventions were noted. Behavior monitoring records dated March 2014 indicated Resident #72 had no behaviors documented and had no side effects from his quitiapine or [MEDICATION NAME]. An incident report completed by LVN A dated 03/12/14 indicted on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated there was "no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." During an interview on 04/26/14 at 9:35 a.m., LVN A said he came in around 9:00 p.m. or 9:15 p.m. to get ready for his shift. When he walked in the door, he heard an alarm going off. He said he did not see any staff at the nursing station or in the halls. He first went down Hall A, and the alarm was not on that hall. He then started down Hall B, and the alarm was going off in Resident #72's room, the first room on the right. He said Resident #72 was lying "face down and unconscious." He said there was blood on the floor. He said he checked for a pulse and respirations and called out for help. He said he saw a contusion above the resident's eye. LVN A said LVN B arrived and took the resident's vital signs. LVN A said he then left and called the doctor for an order to transfer Resident #72 to the hospital. LVN A said he did not write any nursing notes. He said, "I guess I thought (LVN B) would do the the nurses' notes." During an interview on 04/26/14 at 10:05 a.m., LVN A said he called the physician to notify him of what happened. He was not sure how long it was between calling the physician and the ambulance arriving. LVN A said Resident #72 was "face down in front of the bathroom door. It looked like he hit his head on the table or the refrigerator as he fell . He was contorted, had a contusion over his eye, and there was blood on his arm. He was breathing and had a pulse." LVN A could not remember if the resident had any socks or shoes on. LVN A further stated, "When (LVN B) came in, she took his vital signs. I don't remember seeing any staff in any of the hallways when I got to work." LVN A said prior to this incident, Resident #72 had to be carefully watched because he would try to get out of his geri chair all the time when he was awake. He said Resident #72 usually had a pad alarm and a clip alarm because he would pull his clip alarm off. LVN A said when the resident was restless, they would bring him to the nursing station in his geri chair so they could watch him. LVN A said the hospital said the cause of Resident #72's death was bruising on the brain related to this injury. LVN A said the normal staffing for the 2:00 p.m. to 10:00 p.m. shift was 3 nurses and 6 CNAs. A staff sign-in assignment record dated 03/11/14 indicated there were 3 LVNs and 5 CNAs. During an interview on 04/26/14 at 3:55 p.m., CNA C said she put Resident #72 to bed with both his pad (bed) alarm and clip on alarm. She was not sure of the time. CNA C said the bed was in the low position and the door was open. She said she took his dirty linens out then went to the room next door to Resident #72 to assist that resident to bed. She said she was in that resident's room with the door closed. CNA C said she did not hear the alarm in Resident #72's room. CNA C said the first she knew of the incident was when LVN A came to get her for assistance. CNA C said it could not have been more than 10 minutes between putting Resident #72 to bed and LVN A asking for assistance. CNA C said Resident #72 was on the floor by the bathroom door and there was blood on the floor. She said the resident was not talking. She said the resident "came alert" when LVN A asked, "Are you hurt?" CNA C said Resident #72 responded, "I got to get up." CNA C said another nurse came in, but she did not remember who the nurse was. CNA C said Resident #72 did not usually try to get out of bed. She said when the resident was agitated, they would put him in a geri chair at the nursing station. CNA C said when the resident was in bed, they "checked on him a lot" because he was active. CNA C said the ambulance arrived a few minutes before 10:00 p.m. During an observation on 04/26/14 at 4:05 p.m., a surveyor stood in Resident #72's room with the door open and a second surveyor went in the room next door with the door closed. The surveyor separately set off both a pad (bed) alarm and a personal clip alarm in the room that had been Resident #72's. Both could clearly be heard from the next room. At 4:10 p.m., a surveyor stood at the entrance door. Both alarms could clearly be heard when set off. During an interview on 04/26/14 at 4:15 p.m., the treatment nurse said the alarms were always kept on the high setting. The back of the alarms had to be removed to change the setting. She said it could "definitely" be heard if you were in the room next door where an alarm was sounding and could be heard "from one end of the hall to the other." During an interview on 04/26/14 at 4:39 p.m., LVN B said she worked prn (as needed). She said she was in the hall at the opposite end of Hall B from Resident #72's room. She said a CNA, who she could not identify, hollered from Resident #72's room to get some gloves and come quickly. LVN B said she did not hear an alarm. When she came in the room, LVN A was with the resident. The resident was face down on the floor with his arm under him. LVN B said LVN A lifted the resident and got his arm from beneath him. LVN B said she could then see Resident #72 was bleeding from his arm or his hand and had a bruise developing over his eye. She said she applied pressure to his bleeding arm. LVN B said she did not recall the resident saying anything, but he was making some "noises." LVN B said she took Resident #72's vital signs and stated she "could not recall doing a whole lot." She stated, "I was afraid to move him much." She said the time of the incident was between 9:30 p.m. and 9:45 p.m. because she was finishing her medication pass. LVN B said she stayed with Resident #72 while LVN A left to make phone calls to get the resident transported to the ER. LVN A was not sure what time the ambulance arrived. She said she did not document anything about the incident in the nursing notes. LVN B said she thought LVN A did because he was more familiar with the documentation. LVN B said they usually kept Resident #72 in a geri chair at the nursing station where they could watch him more closely. LVN B stated, "We did not dare put the resident to bed before he got sleepy." LVN B said Resident #72 was sleepy earlier than usual that day and they put him to bed. LVN B said she should clearly hear an alarm sounding if she was in the hall. During an interview on 04/26/14 at 4:56 p.m., LVN D said she was the Hall A charge nurse the night of the incident with Resident #72. LVN D said she frequently worked Hall B as well and was familiar with Resident #72. LVN D said if she was down Hall A or if TVs were on loud, she would not hear an alarm on Hall B. LVN D said Resident #72 was very restless and repeatedly tried to get out of his geri chair. She said to keep him safe, she often had to take him in his geri chair down the hall with her so he could see her and she could talk to him. LVN D said she and the CNAs would take turns taking him with them on the hall. She said at times he was so active he required one-on-one supervision. 2. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated active physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. Comprehensive Care Plan dated 02/21/14 for Resident #5 indicated the following: "Problem: "Resident at risk for falls related to history of falls, unsteadiness, weakness, [MEDICAL CONDITION], confusion, multiple meds, and other disease process." Goals: "Resident will be free of falls/injuries related to falls x 90 days." - Approaches: "Gather and assess information on past falls ...encourage to request assist in ambulating;...Refer to therapy;... Notify MD/Family of changes; ...Keep call light in reach and answer promptly." Handwritten updates under the "problems" column of the care plan indicated resident #5 had falls on 02/22/14, 02/26/14, 04/04/14 and 04/16/14 with no injuries. Handwritten updates under the "goals" column of the care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to back of head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 centimeters (cm) abrasion above left eyebrow and on 04/09/14, she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. Resident #5's physical therapy "Resident Screening Form" dated 01/09/14 indicated the resident shows no change. Resident #5's therapy "Resident Screening Form" dated 02/07/14 indicated physical therapy was to evaluate and treat. Resident #5's therapy "Resident Screening Form" dated 03/10/14 indicated the resident was receiving physical therapy. Resident #5's "Therapy Screen" dated 04/16/14 and 04/21/14 indicated the resident showed no changes in abilities. Resident #5 was observed on 04/22/14 at 9:00 a.m., 04/23/14 at 9:20 a.m. and again at 9:35 a.m. in her wheelchair with the chair alarm attached. She was observed on 04/24/14 at 1:10 p.m. at the nurse's station and on 4/26/14 at 3:00 p.m. in the dining room playing bingo with the chair alarm attached. Staff was present each instance. During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. The ADON said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 a.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Conditio

Based on observation, interview, and record review, the facility failed to develop, review, and revise the comprehensive plans of care for 10 of 19 residents reviewed for care plans. (Resident #s 72, 5, 46, 33, 26, 50, 48, 10, 43, and 56) IMMEDIATE JEOPARDY 1. Resident #72 was admitted after breaking his arm during a fall. He sustained two falls after admission and the facility did not make further updates to his plan of care. Resident #72 fell a third time in his room and lost consciousness. The facility did not respond to his bed or personal alarms for an unknown period of time. LVN A heard the alarms and found Resident #72 face down on the floor of his room with a contusion on his forehead and bleeding from his arm. He was sent to the hospital and was diagnosed with [REDACTED]. 2. Resident #5 was readmitted after breaking her hip during a fall. She sustained 20 falls between 01/02/14 and 04/21/14. The facility did not revise or implement interventions following those falls. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. NON-IMMEDIATE JEOPARDY Residents did not have care plans developed for these areas identified by assessment: 3. Resident #46: skin risk, oxygen use, or range of motion impairment. 4. Resident #33: was not suctioned frequently, had a cold room, needed interventions against pressure sore development on her heels, was not taken out of the room for socialization, and had side rails, all of which were per her daughter's request. 5. Resident #26: risperdone (an antipsychotic) use. 6. Resident #50: [MEDICATION NAME] ER (an antidepressant), for frequent nausea requiring the use of [MEDICATION NAME] HCL (anti-nausea), for frequent flatulence requiring the use of simethecone (anti-flatuence), and pain requiring [MEDICATION NAME]-[MEDICATION NAME]. 7. Resident #48: range of motion, [MEDICAL CONDITION] (contagious organism causing diarrhea), or the extent of assistance needed with ADLs. 8. Resident #10: had a recent burn. 9. Resident #43: range of motion 10. Resident #56: transfer assistance after her leg fracture, range of motion, impaired vision, and specialized rehabilitation. This failure could place the census of 70 residents at risk for unmet needs. Findings included: IMMEDIATE JEOPARDY 1. Undated active physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and [MEDICATION NAME] 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An admission MDS dated [DATE] indicated Resident #72 had moderately impaired cognition, physical and verbal behaviors, required extensive assistance of two persons to transfer, did not walk, had a fall with fracture prior to admission, and had 1 fall with no injury since admission. A fall risk care plan dated 01/09/14 indicated Resident #72 was at risk for falls due to increased weakness and decrease in cognition. The goal was for the resident to have no falls for 90 days. Interventions were: "Gather and assess information on past falls; monitor and document signs/symptoms of adverse effects of medications; encourage to request assist in ambulating; clutter-free environment and articles of care within resident's reach; refer to therapy for evaluation as indicated for any (signs/symptoms) of decline; keep call light in reach and answer promptly; assist with transfers and ambulation as needed; and encourage resident to call for assistance as needed and report any signs of dizziness." A personal alarm care plan dated 01/09/14 indicated Resident #72 required use of a personal alarm. The goal was for the resident to have the personal safety alarm attached for the next 90 days. Interventions included: "Resident will have personal alarm attached to self and chair when up in chair; resident will have personal alarm attached to self and bed when in bed; respond immediately to alarm when it goes off..." An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell ." A fall risk care plan dated 01/09/14 indicated a hand written notation dated 02/20/14 indicating Resident #72 had an actual fall on 02/20/14 "neuros started and are (within normal limits)." No new goals or interventions were noted. Behavior monitoring records dated March 2014 indicated Resident #72 had no behaviors documented and had no side effects from his quitiapine or [MEDICATION NAME]. An incident report completed by LVN A dated 03/12/14 indicted on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated there was "no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." During an interview on 04/26/14 at 9:35 a.m., LVN A said he came in around 9:00 p.m. or 9:15 p.m. to get ready for his shift. When he walked in the door, he heard an alarm going off. He said he did not see any staff at the nursing station or in the halls. He first went down Hall A, and the alarm was not on that hall. He then started down Hall B, and the alarm was going off in Resident #72's room, the first room on the right. He said Resident #72 was lying "face down and unconscious." He said there was blood on the floor. He said he checked for a pulse and respirations and called out for help. He said he saw a contusion above the resident's eye. LVN A said LVN B arrived and took the resident's vital signs. LVN A said he then left and called the doctor for an order to transfer Resident #72 to the hospital. LVN A said he did not write any nursing notes. He said, "I guess I thought (LVN B) would do the the nurses' notes." During an interview on 04/26/14 at 10:05 a.m., LVN A said he called the physician to notify him of what happened. He was not sure how long it was between calling the physician and the ambulance arriving. LVN A said Resident #72 was "face down in front of the bathroom door. It looked like he hit his head on the table or the refrigerator as he fell . He was contorted, had a contusion over his eye, and there was blood on his arm. He was breathing and had a pulse." LVN A could not remember if the resident had any socks or shoes on. LVN A further stated, "When (LVN B) came in, she took his vital signs. I don't remember seeing any staff in any of the hallways when I got to work." LVN A said prior to this incident, Resident #72 had to be carefully watched because he would try to get out of his geri chair all the time when he was awake. He said Resident #72 usually had a pad alarm and a clip alarm because he would pull his clip alarm off. LVN A said when the resident was restless, they would bring him to the nursing station in his geri chair so they could watch him. LVN A said the hospital said the cause of Resident #72's death was bruising on the brain related to this injury. LVN A said the normal staffing for the 2:00 p.m. to 10:00 p.m. shift was 3 nurses and 6 CNAs. A staff sign-in assignment record dated 03/11/14 indicated there were 3 LVNs and 5 CNAs. During an interview on 04/26/14 at 3:55 p.m., CNA C said she put Resident #72 to bed with both his pad (bed) alarm and clip on alarm. She was not sure of the time. CNA C said the bed was in the low position and the door was open. She said she took his dirty linens out then went to the room next door to Resident #72 to assist that resident to bed. She said she was in that resident's room with the door closed. CNA C said she did not hear the alarm in Resident #72's room. CNA C said the first she knew of the incident was when LVN A came to get her for assistance. CNA C said it could not have been more than 10 minutes between putting Resident #72 to bed and LVN A asking for assistance. CNA C said Resident #72 was on the floor by the bathroom door and there was blood on the floor. She said the resident was not talking. She said the resident "came alert" when LVN A asked, "Are you hurt?" CNA C said Resident #72 responded, "I got to get up." CNA C said another nurse came in, but she did not remember who the nurse was. CNA C said Resident #72 did not usually try to get out of bed. She said when the resident was agitated, they would put him in a geri chair at the nursing station. CNA C said when the resident was in bed, they "checked on him a lot" because he was active. CNA C said the ambulance arrived a few minutes before 10:00 p.m. During an observation on 04/26/14 at 4:05 p.m., a surveyor stood in Resident #72's room with the door open and a second surveyor went in the room next door with the door closed. The surveyor separately set off both a pad (bed) alarm and a personal clip alarm in the room that had been Resident #72's. Both could clearly be heard from the next room. At 4:10 p.m., a surveyor stood at the entrance door. Both alarms could clearly be heard when set off. During an interview on 04/26/14 at 4:15 p.m., the treatment nurse said the alarms were always kept on the high setting. The back of the alarms had to be removed to change the setting. She said it could "definitely" be heard if you were in the room next door where an alarm was sounding and could be heard "from one end of the hall to the other." During an interview on 04/26/14 at 4:39 p.m., LVN B said she worked prn (as needed). She said she was in the hall at the opposite end of Hall B from Resident #72's room. She said a CNA, who she could not identify, hollered from Resident #72's room to get some gloves and come quickly. LVN B said she did not hear an alarm. When she came in the room, LVN A was with the resident. The resident was face down on the floor with his arm under him. LVN B said LVN A lifted the resident and got his arm from beneath him. LVN B said she could then see Resident #72 was bleeding from his arm or his hand and had a bruise developing over his eye. She said she applied pressure to his bleeding arm. LVN B said she did not recall the resident saying anything, but he was making some "noises." LVN B said she took Resident #72's vital signs and stated she "could not recall doing a whole lot." She stated, "I was afraid to move him much." She said the time of the incident was between 9:30 p.m. and 9:45 p.m. because she was finishing her medication pass. LVN B said she stayed with Resident #72 while LVN A left to make phone calls to get the resident transported to the ER. LVN A was not sure what time the ambulance arrived. She said she did not document anything about the incident in the nursing notes. LVN B said she thought LVN A did because he was more familiar with the documentation. LVN B said they usually kept Resident #72 in a geri chair at the nursing station where they could watch him more closely. LVN B stated, "We did not dare put the resident to bed before he got sleepy." LVN B said Resident #72 was sleepy earlier than usual that day and they put him to bed. LVN B said she should clearly hear an alarm sounding if she was in the hall. During an interview on 04/26/14 at 4:56 p.m., LVN D said she was the Hall A charge nurse the night of the incident with Resident #72. LVN D said she frequently worked Hall B as well and was familiar with Resident #72. LVN D said if she was down Hall A or if TVs were on loud, she would not hear an alarm on Hall B. LVN D said Resident #72 was very restless and repeatedly tried to get out of his geri chair. She said to keep him safe, she often had to take him in his geri chair down the hall with her so he could see her and she could talk to him. LVN D said she and the CNAs would take turns taking him with them on the hall. She said at times he was so active he required one-on-one supervision. 2. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated active physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. Comprehensive Care Plan dated 02/21/14 for Resident #5 indicated the following: "Problem: "Resident at risk for falls related to history of falls, unsteadiness, weakness, [MEDICAL CONDITION], confusion, multiple meds, and other disease process." Goals: "Resident will be free of falls/injuries related to falls x 90 days." - Approaches: "Gather and assess information on past falls ...encourage to request assist in ambulating;...Refer to therapy;... Notify MD/Family of changes; ...Keep call light in reach and answer promptly." Handwritten updates under the "problems" column of the care plan indicated resident #5 had falls on 02/22/14, 02/26/14, 04/04/14 and 04/16/14 with no injuries. Handwritten updates under the "goals" column of the care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to back of head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 cm (centimeter) abrasion above left eyebrow and on 04/09/14 she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. Resident #5's physical therapy "Resident Screening Form" dated 01/09/14 indicated the resident shows no change. Resident #5's therapy "Resident Screening Form" dated 02/07/14 indicated physical therapy was to evaluate and treat. Resident #5's therapy "Resident Screening Form" dated 03/10/14 indicated the resident was receiving physical therapy. Resident #5's "Therapy Screen" dated 04/16/14 and 04/21/14 indicated the resident showed no changes in abilities. Resident #5 was observed on 04/22/14 at 9:00 a.m., 04/23/14 at 9:20 a.m. and again at 9:35 a.m. in her wheelchair with the chair alarm attached. She was observed on 04/24/14 at 1:10 p.m. at the nurse's station and on 4/26/14 at 3:00 p.m. in the dining room playing bingo with the chair alarm attached. Staff was present each instance. During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. The ADON said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. The undated policy titled Abuse Prohibition Management Program indicated, "Our Facility will not condone resident abuse, neglect, or mistreatment...Prevention: 5. ...e. The assessment care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents...who require heavy nursing care and/or are totally dependent on staff...Procedures: Identification: 1. h. Neglect is...a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." A Falls and Fall Risk, Managing Policy and Procedure revised December 2007 indicated the following: "Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify apprpriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If inderlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions...to try to minimize serous consequences of fallilng. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling... 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions... 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls." The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 a.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Condition form in addition to an Incident Report for every resident fall within one hour of fall. The Change of Condition Form prompts and documents comprehensive assessment of resident's condition and communication to the attending physician of the situation, background and assessment/appearance within 24 hours. 2. Charge nurses will be in-serviced on Change of Condition/Fall documentation prior to next shift by management nurses beginning 4/26/14. 3. DON/Administrator will review each incident report to ensure that an appropriate Change of Condition was completed and that the physician was notified timely of the resident's assessment/appearance and condition within 24 hours. Nurses found not to be in compliance will receive written counseling up to and including termination or further education as appropriate. 4. The DON and/or Administrator will be notified of any falls resulting in transfer to a hospital setting within 30 minutes. 5. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. 6. The QA/PI Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs were interviewed and were able to identify the risk factors that could lead to falls, ways to keep the environment safe, ways to assist residents who were at risk for falls, monitor residents who had a fall, and ways to prevent further falls should one occur, and how to monitor alarms were in place as ordered. Five LVNs and one RN were interviewed and were able to identify what documentation to do should a resident have a fall, who to notify, when to update care plans, when a fall risk assessment should be completed and within what time-frame, and when and how to initiate an investigation if a resident experienced a fall, and how to monitor that alarms were in place correctly. Fall risk assessments for 7 residents at high risk for falls were reviewed and the assessments had been updated as of 04/26/14. Care plans for 7 residents at high risk for falls were reviewed and the care plans had been updated as of 04/26/14. On 04/27/14 at 3:52 p.m., the administrator, corporate RN, and ADON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. NON IMMEDIATE JEOPARDY 3. Undated active physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for 2 of 4 halls (Halls A and B) and each resident received adequate supervision and assistance devices to prevent accidents for 7 of 11 residents reviewed for accident supervision. (Resident #s 72, 5, 10, 1, 2, 56, 65, 8, 9, and 36) IMMEDIATE JEOPARDY 1. Resident #72 was admitted after breaking his arm during a fall. He sustained two falls after admission and the facility did not make further updates to his plan of care. Resident #72 fell a third time in his room and lost consciousness. The facility did not respond to his bed or personal alarms for an unknown period of time. LVN A heard the alarms and found Resident #72 face down on the floor of his room with a contusion on his forehead and bleeding from his arm. He was sent to the hospital and was diagnosed with [REDACTED]. 2. Resident #5 was readmitted after breaking her hip during a fall. She sustained 20 falls between 01/02/14 and 04/21/14. The facility did not revise or implement interventions following those falls. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. NON-IMMEDIATE JEOPARDY 3. Resident #10 sustained a 1st degree burn and no interventions were put into place to prevent accidents. 4. Resident #1 had two falls and interventions were not implemented. 5. Water temperatures in Room 119 were 136.3 F and at the hand sink in the shower room on Hall B were 129.3 degrees F (Fahrenheit). 6. CNA H transferred Resident #2 into bed without locking the brakes on her Geri-chair. The Geri-chair rolled back slightly during the transfer. 7. CNA S made Resident #56 stand in the shower with knowledge Resident #56 was weak. CNA S did not call for assistance and Resident #56 slid. 8. CNAs L and P transferred Resident #56 without locking the wheelchair. The wheelchair rolled slightly backwards when Resident #56 was assisted to stand and placed Resident #56 in bed. 9. Twelve Disposable razors were found in the rooms of Resident #s 65, 8, and 9. Resident #65 had confusion at times and Resident #8 was confused. Resident #36 had periods of wandering in other resident rooms and using the bathroom. This failure could place 23 residents residing on Hall B at risk of exposure to uncomfortable or unsafe water temperatures. This failure could place 23 residents residing on Hall A at risk of injury. This failure could place 44 residents requiring one or two staff assistance for transfer at risk of injury. This failure could place 54 residents who were at risk for falls at risk for serious injury or death in the event of a fall. Findings included: IMMEDIATE JEOPARDY 1. Undated physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and sertraline 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An admission MDS dated [DATE] indicated Resident #72 had moderately impaired cognition, physical and verbal behaviors, required extensive assistance of two persons to transfer, did not walk, had a fall with fracture prior to admission, and had 1 fall with no injury since admission. A fall risk care plan dated 01/09/14 indicated Resident #72 was at risk for falls due to increased weakness and decrease in cognition. The goal was for the resident to have no falls for 90 days. Interventions were: "Gather and assess information on past falls; monitor and document signs/symptoms of adverse effects of medications; encourage to request assist in ambulating; clutter-free environment and articles of care within resident's reach; refer to therapy for evaluation as indicated for any (signs/symptoms) of decline; keep call light in reach and answer promptly; assist with transfers and ambulation as needed; and encourage resident to call for assistance as needed and report any signs of dizziness." A personal alarm care plan dated 01/09/14 indicated Resident #72 required use of a personal alarm. The goal was for the resident to have the personal safety alarm attached for the next 90 days. Interventions included: "Resident will have personal alarm attached to self and chair when up in chair; resident will have personal alarm attached to self and bed when in bed; respond immediately to alarm when it goes off..." An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell ." A fall risk care plan dated 01/09/14 indicated a hand written notation dated 02/20/14 indicating Resident #72 had an actual fall on 02/20/14 "neuros started and are (within normal limits)." No new goals or interventions were noted. Behavior monitoring records dated March 2014 indicated Resident #72 had no behaviors documented and had no side effects from his quitiapine or sertraline. An incident report completed by LVN A dated 03/12/14 indicted on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated "there was no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." During an interview on 04/26/14 at 9:35 a.m., LVN A said he came in around 9:00 p.m. or 9:15 p.m. to get ready for his shift. When he walked in the door, he heard an alarm going off. He said he did not see any staff at the nursing station or in the halls. He first went down Hall A, and the alarm was not on that hall. He then started down Hall B, and the alarm was going off in Resident #72's room, the first room on the right. He said Resident #72 was lying "face down and unconscious." He said there was blood on the floor. He said he checked for a pulse and respirations and called out for help. He said he saw a contusion above the resident's eye. LVN A said LVN B arrived and took the resident's vital signs. LVN A said he then left and called the doctor for an order to transfer Resident #72 to the hospital. LVN A said he did not write any nursing notes. He said, "I guess I thought (LVN B) would do the the nurses' notes." During an interview on 04/26/14 at 10:05 a.m., LVN A said he called the physician to notify him of what happened. He was not sure how long it was between calling the physician and the ambulance arriving. LVN A said Resident #72 was "face down in front of the bathroom door. It looked like he hit his head on the table or the refrigerator as he fell . He was contorted, had a contusion over his eye, and there was blood on his arm. He was breathing and had a pulse." LVN A could not remember if the resident had any socks or shoes on. LVN A further stated, "When (LVN B) came in, she took his vital signs. I don't remember seeing any staff in any of the hallways when I got to work." LVN A said prior to this incident, Resident #72 had to be carefully watched because he would try to get out of his geri chair all the time when he was awake. He said Resident #72 usually had a pad alarm and a clip alarm because he would pull his clip alarm off. LVN A said when the resident was restless, they would bring him to the nursing station in his geri chair so they could watch him. LVN A said the hospital said the cause of Resident #72's death was bruising on the brain related to this injury. LVN A said the normal staffing for the 2:00 p.m. to 10:00 p.m. shift was 3 nurses and 6 CNAs. A staff sign-in assignment record dated 03/11/14 indicated there were 3 LVNs and 5 CNAs. During an interview on 04/26/14 at 3:55 p.m., CNA C said she put Resident #72 to bed with both his pad (bed) alarm and clip on alarm. She was not sure of the time. CNA C said the bed was in the low position and the door was open. She said she took his dirty linens out then went to the room next door to Resident #72 to assist that resident to bed. She said she was in that resident's room with the door closed. CNA C said she did not hear the alarm in Resident #72's room. CNA C said the first she knew of the incident was when LVN A came to get her for assistance. CNA C said it could not have been more than 10 minutes between putting Resident #72 to bed and LVN A asking for assistance. CNA C said Resident #72 was on the floor by the bathroom door and there was blood on the floor. She said the resident was not talking. She said the resident "came alert" when LVN A asked, "Are you hurt?" CNA C said Resident #72 responded, "I got to get up." CNA C said another nurse came in, but she did not remember who the nurse was. CNA C said Resident #72 did not usually try to get out of bed. She said when the resident was agitated, they would put him in a geri chair at the nursing station. CNA C said when the resident was in bed, they "checked on him a lot" because he was active. CNA C said the ambulance arrived a few minutes before 10:00 p.m. During an observation on 04/26/14 at 4:05 p.m., a surveyor stood in Resident #72's room with the door open and a second surveyor went in the room next door with the door closed. The surveyor separately set off both a pad (bed) alarm and a personal clip alarm in the room that had been Resident #72's. Both could clearly be heard from the next room. At 4:10 p.m., a surveyor stood at the entrance door. Both alarms could clearly be heard when set off. During an interview on 04/26/14 at 4:15 p.m., the treatment nurse said the alarms were always kept on the high setting. The back of the alarms had to be removed to change the setting. She said it could "definitely" be heard if you were in the room next door where an alarm was sounding and could be heard "from one end of the hall to the other." During an interview on 04/26/14 at 4:39 p.m., LVN B said she worked prn (as needed). She said she was in the hall at the opposite end of Hall B from Resident #72's room. She said a CNA, who she could not identify, hollered from Resident #72's room to get some gloves and come quickly. LVN B said she did not hear an alarm. When she came in the room, LVN A was with the resident. The resident was face down on the floor with his arm under him. LVN B said LVN A lifted the resident and got his arm from beneath him. LVN B said she could then see Resident #72 was bleeding from his arm or his hand and had a bruise developing over his eye. She said she applied pressure to his bleeding arm. LVN B said she did not recall the resident saying anything, but he was making some "noises." LVN B said she took Resident #72's vital signs and stated she "could not recall doing a whole lot." She stated, "I was afraid to move him much." She said the time of the incident was between 9:30 p.m. and 9:45 p.m. because she was finishing her medication pass. LVN B said she stayed with Resident #72 while LVN A left to make phone calls to get the resident transported to the ER. LVN A was not sure what time the ambulance arrived. She said she did not document anything about the incident in the nursing notes. LVN B said she thought LVN A did because he was more familiar with the documentation. LVN B said they usually kept Resident #72 in a geri chair at the nursing station where they could watch him more closely. LVN B stated, "We did not dare put the resident to bed before he got sleepy." LVN B said Resident #72 was sleepy earlier than usual that day and they put him to bed. LVN B said she should clearly hear an alarm sounding if she was in the hall. During an interview on 04/26/14 at 4:56 p.m., LVN D said she was the Hall A charge nurse the night of the incident with Resident #72. LVN D said she frequently worked Hall B as well and was familiar with Resident #72. LVN D said if she was down Hall A or if TVs were on loud, she would not hear an alarm on Hall B. LVN D said Resident #72 was very restless and repeatedly tried to get out of his geri chair. She said to keep him safe, she often had to take him in his geri chair down the hall with her so he could see her and she could talk to him. LVN D said she and the CNAs would take turns taking him with them on the hall. She said at times he was so active he required one-on-one supervision. 2. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated active physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. Comprehensive Care Plan dated 02/21/14 for Resident #5 indicated the following: "Problem: "Resident at risk for falls related to history of falls, unsteadiness, weakness, osteoporosis, confusion, multiple meds, and other disease process." Goals: "Resident will be free of falls/injuries related to falls x 90 days." - Approaches: "Gather and assess information on past falls ...encourage to request assist in ambulating;...Refer to therapy;... Notify MD/Family of changes; ...Keep call light in reach and answer promptly." Handwritten updates under the "problems" column of the care plan indicated resident #5 had falls on 02/22/14, 02/26/14, 04/04/14 and 04/16/14 with no injuries. Handwritten updates under the "goals" column of the care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to back of head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 cm (centimeter) abrasion above left eyebrow and on 04/09/14, she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. Resident #5's physical therapy "Resident Screening Form" dated 01/09/14 indicated the resident shows no change. Resident #5's therapy "Resident Screening Form" dated 02/07/14 indicated physical therapy was to evaluate and treat. Resident #5's therapy "Resident Screening Form" dated 03/10/14 indicated the resident was receiving physical therapy. Resident #5's "Therapy Screen" dated 04/16/14 and 04/21/14 indicated the resident showed no changes in abilities. Resident #5 was observed on 04/22/14 at 9:00 a.m., 04/23/14 at 9:20 a.m. and again at 9:35 a.m. in her wheelchair with the chair alarm attached. She was observed on 04/24/14 at 1:10 p.m. at the nurse's station and on 4/26/14 at 3:00 p.m. in the dining room playing bingo with the chair alarm attached. Staff was present each instance. During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. The ADON said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. The undated policy titled Abuse Prohibition Management Program indicated, "Our Facility will not condone resident abuse, neglect, or mistreatment... Prevention: 5. ...e. The assessment care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents...who require heavy nursing care and/or are totally dependent on staff...Procedures: Identification: 1. h. Neglect is...a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." A Falls and Fall Risk, Managing Policy and Procedure revised December 2007 indicated the following: "Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify apprpriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If inderlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions...to try to minimize serous consequences of fallilng. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling... 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions... 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls." The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 a.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Condition form in addition to an Incident Report for every resident fall within one hour of fall. The Change of Condition Form prompts and documents comprehensive assessment of resident's condition and communication to the attending physician of the situation, background and assessment/appearance within 24 hours. 2. Charge nurses will be in-serviced on Change of Condition/Fall documentation prior to next shift by management nurses beginning 4/26/14. 3. DON/Administrator will review each incident report to ensure that an appropriate Change of Condition was completed and that the physician was notified timely of the resident's assessment/appearance and condition within 24 hours. Nurses found not to be in compliance will receive written counseling up to and including termination or further education as appropriate. 4. The DON and/or Administrator will be notified of any falls resulting in transfer to a hospital setting within 30 minutes. 5. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. 6. The QA/PI Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs were interviewed and were able to identify the risk factors that could lead to falls, ways to keep the environment safe, ways to assist residents who were at risk for falls, monitor residents who had a fall, and ways to prevent further falls should one occur, and how to monitor alarms were in place as ordered. Five LVNs and one RN were interviewed and were able to identify what documentation to do should a resident have a fall, who to notify, when to update care plans, when a fall risk assessment should be completed and within what time-frame, and when and how to initiate an investigation if a resident experienced a fall, and how to monitor that alarms were in place correctly. Fall risk assessments for 7 residents at high risk for falls were reviewed and the assessments had been updated as of 04/26/14. Care plans for 7 residents at high risk for falls were reviewed and the care plans had been updated as of 04/26/14. On 04/27

Based on interview and record review, the administrator, DON and ADON failed to administer in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 11 residents reviewed for falls. (Resident #s 72 and 5) Two residents sustained multiple falls without changes of interventions or care plan updates to prevent further falls. The administrator did not monitor the DON and ADON to ensure facility policies regarding neglect and accident prevention were implemented. The DON and ADON did not review the documentation following the falls, investigate the falls, put other measures in place to ensure other residents at risk for falls had appropriate interventions, train and supervise the nursing staff regarding proper fall interventions, implement the facility policies regarding neglect and accident prevention were implemented. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. This failure could place 54 residents who were at risk for falls, 21 who had alarms, at risk for serious injury or death in the event of a fall. Findings included: During an interview on entrance on 04/22/14 at 8:45 a.m., the administrator said the DON would not be available for the survey. She was on vacation. During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. She said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. During an interview on 04/27/14 at 3:20 p.m., the administrator said staff had daily stand up meetings, weekly standards of care meetings, and monthly QA meetings which the medical director attended. Falls had been looked at, but not identified as a concern. The administrator said she felt the main reason the Immediate Jeopardy with Resident #72 occurred was the LG computer system was new and the staff were still learning how to use the system. She said she felt the incident with Resident #72 was an isolated incident where he just got up and fell . She said she saw the incident report and transfer form. She said she did not look for nursing notes or any other documentation. related to the fall. The administrator said she had policies and procedures, consultants, sister facilities, and the medical director as additional resources. She said since the Immediate Jeopardy, she had contacted sister facilities and regional staff for ideas on fall prevention. 1. Undated physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and [MEDICATION NAME] 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell . An incident report completed by LVN A dated 03/12/14 indicted on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated there was "no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." 2. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated current physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. The care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to back of head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 cm (centimeter) abrasion above left eyebrow and on 04/09/14, she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. A Falls and Fall Risk, Managing Policy and Procedure revised December 2007 indicated the following: "Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify apprpriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If inderlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions...to try to minimize serous consequences of fallilng. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling... 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions... 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls." The undated policy titled Abuse Prohibition Management Program indicated, "Our Facility will not condone resident abuse, neglect, or mistreatment... Prevention: 5. ...e. The assessment care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents...who require heavy nursing care and/or are totally dependent on staff...Procedures: Identification: 1. h. Neglect is...a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 a.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Condition form in addition to an Incident Report for every resident fall within one hour of fall. The Change of Condition Form prompts and documents comprehensive assessment of resident's condition and communication to the attending physician of the situation, background and assessment/appearance within 24 hours. 2. Charge nurses will be in-serviced on Change of Condition/Fall documentation prior to next shift by management nurses beginning 4/26/14. 3. DON/Administrator will review each incident report to ensure that an appropriate Change of Condition was completed and that the physician was notified timely of the resident's assessment/appearance and condition within 24 hours. Nurses found not to be in compliance will receive written counseling up to and including termination or further education as appropriate. 4. The DON and/or Administrator will be notified of any falls resulting in transfer to a hospital setting within 30 minutes. 5. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. 6. The QA/PI Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs were interviewed and were able to identify the risk factors that could lead to falls, ways to keep the environment safe, ways to assist residents who were at risk for falls, monitor residents who had a fall, and ways to prevent further falls should one occur, and how to monitor alarms were in place as ordered. Five LVNs and one RN were interviewed and were able to identify what documentation to do should a resident have a fall, who to notify, when to update care plans, when a fall risk assessment should be completed and within what time-frame, and when and how to initiate an investigation if a resident experienced a fall, and how to monitor that alarms were in place correctly. Fall risk assessments for 7 residents at high risk for falls were reviewed and the assessments had been updated as of 04/26/14. Care plans for 7 residents at high risk for falls were reviewed and the care plans had been updated as of 04/26/14. On 04/27/14 at 3:52 p.m., the administrator, corporate RN, and ADON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 04/27/14 at 4:30 p.m., the administrator indicated 54 residents were at risk for falls, 21 of those had alarms. Cross reference F224, F225, F226, F279, F309, F323, and F520.

Based on interview and record review, the facility failed to ensure their QAA (Quality Assessment and Assurance) committee identified, developed and implemented plans of action to correct quality deficiencies for the facility. The QAA did not identify and implement plans of action to correct quality deficiencies in the areas of infection control, accident hazards, care plans, and abuse/neglect. Two residents sustained multiple falls without identification by the QAA committee to prevent further falls. There were multiple infection control failures. The QAA committee discussed infection control, but had not identified or corrected the problems. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. This failure could place the census of 70 at risk for cross contamination, infections, injuries, abuse and neglect and death. Findings included: During an interview on 04/25/14 at 3:00 p.m., the administrator said the QAA committee met monthly. The administrator said when staff identified issues that required attention, they would bring respective topics and reports to the meeting for discussion. She said examples of issues discussed at the QAA meetings were infection control, weight loss, catheters and falls. The administrator said during the meetings the committee "brainstormed" about identified issues. She said they had not identified any quality deficiencies, but had updated about their disaster plan and changed some evacuation sites. During an interview on 04/26/14 at 8:15 a.m., the administrator said the quality of care concerns (infection control, accident hazards, assessments and abuse and neglect) identified during the survey process had been discussed in the QAA meetings. However, nothing had ever been flagged as something that needed a plan of action. On 04/23/14 at 1:00 p.m., the administrator presented a blank undated QAA agenda indicating the following topics were discussed: pressure ulcers, number of residents with weight loss, Foley catheters, number of residents with restraints, falls, infections, [MEDICAL CONDITION] medications, therapeutic pharmacy, bowel and bladder program, and urinary incontinence. During an interview on 04/25/14 at 11:50 a.m., LVN W said she attended QAA meetings and she brings her infection control reports. She also said they discuss all the things on the agenda but could not think of anything specific they had discussed. She said no problems were identified. Accidents A. Undated physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and [MEDICATION NAME] 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell . An incident report completed by LVN A dated 03/12/14 indicated on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated there was "no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. She said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. During an interview on 04/27/14 at 3:20 p.m., the administrator said staff had daily stand up meetings, weekly standards of care meetings, and monthly QA meetings which the medical director attended. Falls had been looked at, but not identified as a concern. The administrator said she felt the main reason the Immediate Jeopardy with Resident #72 occurred was the LG computer system was new and the staff were still learning how to use the system. She said she felt the incident with Resident #72 was an isolated incident where he just got up and fell . She said she saw the incident report and transfer form. She said she did not look for nursing notes or any other documentation. related to the fall. The administrator said she had policies and procedures, consultants, sister facilities, and the medical director as additional resources. She said since the Immediate Jeopardy, she had contacted sister facilities and regional staff for ideas on fall prevention. B. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated current physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. The care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to back of head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 cm (centimeter) abrasion above left eyebrow and on 04/09/14, she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. Infection Control A. During an observation on 04/24/14 at 11:55 a.m., CNAs X and J donned gloves and provided incontinent care for Resident #43. The CNAs did not wash their hands following incontinent care. B. During an observation of wound treatment and incontinent care for Resident #46 on 04/23/14 at 11:38 a.m., the treatment nurse contaminated Resident #46's wound. The treatment nurse and CNA F did not see feces on the resident's rectum until surveyor intervention. CNA F wiped repeatedly back and forth across the buttocks and leg folds with the same wipe. The treatment nurse touched soiled items with ungloved hands, did not wash her hands and touched clean items. CNA F did not change gloves and wash her hands. C. During an observation on 04/23/14 at 5:15 p.m., CNA H touched the dresser and applied [MEDICATION NAME] (skin barrier) to Resident #2. She did not wear gloves to apply a clean brief. D. During an observation on 04/23/14 at 3:20 p.m., CNA S did not change gloves or wash her hands during peri care for Resident #56. An undated Peri-Care policy noted, "...Always maintain good infection control and remember to wash your hands before and after care and the aide may use alcohol gel at bedside for time management because each time they change their gloves they must clean their hands before applying a new pair of gloves. Remember that you can use alcohol gel 3 times before you must wash your hands..." A "Handwashing/Hand Hygiene" policy and procedure revised December 2007 included the following: "...5. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hand are visibly dirty or soiled with blood or other body fluids; c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; 3. After handling items potentially contaminated with blood, body fluids, or secretions..." E. Undated active physician orders [REDACTED].#48 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #48 had received antibiotic for an intestinal infection due to [MEDICAL CONDITION]. During an interview and observation on 04/22/14 at 10:29 a.m., LVN E said Resident #48 recently completed antibiotics for [MEDICAL CONDITION], but had some loose stools. LVN E said a stool specimen was collected that day, 04/22/14, but Resident #48 was not in isolation. During an interview on 04/24/14 at 11:11 a.m., the ADON said Resident #48 was not placed in isolation until they received the lab results indicating positive for [MEDICAL CONDITION]. A [MEDICAL CONDITION] policy dated 11/23/10 included, "...Upon suspicion and/or physician order, residents must be placed into contact isolation until c. (,[MEDICAL CONDITION].) difficile is diagnosed or ruled out..." F. Undated active physician orders [REDACTED]. An infection report dated 04/11/14 indicated Resident #67 was positive for [MEDICAL CONDITION] as of 04/10/14. During an interview on 04/22/14 at 10:25 a.m., Resident #67 said he had been on isolation for 12 days. During an observation and interview after lunch on 04/23/14 at 12:44 p.m., Resident #67's tray was on the cart with other trays. It was on a rack by itself and did not touch other trays. The tray was not bagged. CNA T said Resident #67's tray was not bagged and should have been. During an interview on 04/23/14 at 12:46 p.m., LVN Q said Resident #67's tray should be placed in a trash bag and taken to the kitchen. During an interview on 04/23/14 at 12:49 p.m., LVN W said she was responsible for infection control and Resident #67's tray should be bagged when removed from the room. A universal precautions policy and procedure revised 2013 indicated "Food tray and utensils are handled in such a way as to prevent any contamination of food or utensils. 1. Reusable trays, dishes, glassware, cups and utensils will be used for all residents, regardless of isolation precautions... 3. At the end of the meal, each of the isolation trays and contents will be individually placed in a trash bag by nursing personnel for transport to the dish room." G. During an observation of [MEDICAL CONDITION] care on 04/25/14 at 5:25 p.m., LVN O did not sanitize the overbed table before putting down a barrier for Resident #33's [MEDICAL CONDITION] care. The treatment nurse did not sanitize a folding table used during [MEDICAL CONDITION] care before putting it back on her cart. H. During an observation on 04/25/14 at 11:05 a.m., the treatment nurse did not sanitize a folding table used during wound care for Resident #51. I. During an observations of the laundry area on 04/23/14 beginning at 8:24 a.m., an igloo cooler and biohazard box were on the floor in the laundry. A box fan was on the folding table in the laundry blowing on clean linen. An undated Laundry Policy noted, "...Nothing can be stored on the floor..." J. During an observation on 04/22/14 beginning at 9:40 a.m., 7 bath pans for residents who roomed together: Resident #s 31 and 66, and Resident #s 37, and 38 were not identified. The undated Policy and Procedure on Infection Control indicated: "Policy Statement: The primary purposes of this facility's infection control policies and procedures are to establish guidelines to follow to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Policy Interpretation and Implementation 1. This facility's infection control policies and procedures apply equally to all personnel, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, and marital or veteran status. 2. The objectives of our infection control policies and procedures are to: a. Investigate, control, and prevent infections in the facility. b. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the general public; c. Establish guidelines to follow in the implementation of Isolation precautions d. Maintain records of incidents and corrective actions related to infections; e. Establish guidelines to follow in implementing Standard Precautions for the handling of blood, body fluids, secretions, excretions, mucous membranes and non-intact skin.;... 3. It shall be the responsibility of the Quality Assessment and Assurance Committee, through the Infection Control Committee, to assure that infection control polices and procedures are implemented and followed. 4. All personnel will be informed of our infection control policies and procedures through our orientation program and regularly scheduled in-service training classes. 5. The Governing Board, through the Quality Assessment and Assurance and the Infection Control Committees, has adopted our infection control polices and procedures, as outlined herein, as those that best reflect the needs and operational requirements of this facility in the prevention of transmission of infections and communicable diseases as set forth in current OBRA,OSHA, and CDC guidelines and recommendations." During an interview on 04/25/14 at 3:30 p.m., the ADON said the infection control policy was the infection program. The undated QAA Plan policy and procedure indicated: "The primary purposes of the QAA Plan are: 1. To provide a means whereby negative outcomes relative to resident care and safety can be identified and resolved through an interdisciplinary approach, and effective systems of services and positive care measures rendered can be reinforced and expanded to improve care given; 2. To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing QAA Program, encompassing all aspects of resident care including safety, infection control, and quality of life applicable to nursing home residents; 3. To develop monitoring tools that provide an effective mechanism to assure that each resident receives the necessary care and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being; 4. To assist departments, consultants, and ancillary services that provide direct or indirect care to residents to delineate lines of authority, responsibility, and accountability so that open lines of communication and negative outcome resolutions may be achieved for optimum resident care on a continuous basis; 5. To develop plans of correction and evaluate corrective actions taken to obtain the desired results; and 6. To provide a centralized, coordinated approach to quality assessment and assurance activities so as to bring about a comprehensive program of quality assessment and assurance to meet the needs of the facility." The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 a.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Condition form in addition to an Incident Report for every resident fall within one hour of fall. The Change of Condition Form prompts and documents comprehensive assessment of resident's condition and communication to the attending physician of the situation, background and assessment/appearance within 24 hours. 2. Charge nurses will be in-serviced on Change of Condition/Fall documentation prior to next shift by management nurses beginning 4/26/14. 3. DON/Administrator will review each incident report to ensure that an appropriate Change of Condition was completed and that the physician was notified timely of the resident's assessment/appearance and condition within 24 hours. Nurses found not to be in compliance will receive written counseling up to and including termination or further education as appropriate. 4. The DON and/or Administrator will be notified of any falls resulting in transfer to a hospital setting within 30 minutes. 5. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. 6. The QA/PI Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs were interviewed and were able to identify the risk factors that could lead to falls, ways to keep the environment safe, ways to assist residents who were at risk for falls, monitor residents who had a fall, and ways to prevent further falls should one occur, and how to monitor alarms were in place as ordered. Five LVNs and one RN were interviewed and were able to identify what documentation to do should a resident have a fall, who to notify, when to update care plans, when a fall risk assessment should be completed and within what time-frame, and when and how to initiate an investigation if a resident experienced a fall, and how to monitor that alarms were in place correctly. Fall risk assessments for 7 residents at high risk for falls were reviewed and the assessments had been updated as of 04/26/14. Care plans for 7 residents at high risk for falls were reviewed and the care plans had been updated as of 04/26/14. On 04/27/14 at 3:52 p.m., the administrator, corporate RN, and ADON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 04/22/14 indicated a census of 70. Cross reference F224, F225, F226, F279, F309, F323, F441, and F490.

Based on observation, interview, and record review, the facility failed to implement policies and procedures to prevent neglect for 2 of 14 residents reviewed for neglect. (Resident #s 72 and 5) 1. Resident #72 was admitted after breaking his arm during a fall. He sustained two falls after admission and the facility did not make further updates to his plan of care. Resident #72 fell a third time in his room and lost consciousness. The facility did not respond to his bed or personal alarms for an unknown period of time. LVN A heard the alarms and found Resident #72 face down on the floor of his room with a contusion on his forehead and bleeding from his arm. He was sent to the hospital and was diagnosed with [REDACTED]. 2. Resident #5 was readmitted after breaking her hip during a fall. She sustained 20 falls between 01/02/14 and 04/21/14. The facility did not revise or implement interventions following those falls. An Immediate Jeopardy situation was identified on 04/26/14. The Immediate Jeopardy was removed on 04/27/14. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure likely contributed to the death of Resident #72. This failure could place 54 residents who were at risk for falls, 21 of whom had alarms, at risk for serious injury or death in the event of a fall. Findings included: 1. Undated physician orders [REDACTED].#72 was an [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received quitiapine 100 mg at bedtime for anxiety and [MEDICATION NAME] 100 mg each morning for depression. The orders also indicated physical, occupational, and speech therapies were to evaluate and treat. Admission physician orders [REDACTED].#72 may have a personal safety alarm and bed alarm. An initial care plan dated 01/02/14 indicated Resident #72 had a fracture and mood symptoms. There were no interventions or goals documented. Falls were not addressed as an issue. Fall risk assessments for Resident #72 dated 01/02/14, 01/14/14, and 02/20/14 were all scored 26, high risk for falls. The assessment also indicated, "If a resident is scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan..." No interventions were documented on the fall risk assessments. An incident report dated 01/05/14 indicated Resident #72 was in his room and got up without assistance. An unidentified CNA responded to his alarm, assisted him to stand, and he sat on the floor. He had no injury. The report indicated preventative measures before the incident were a personal alarm. The report indicated interventions following the incident were to continue the use of the personal alarm. An admission MDS dated [DATE] indicated Resident #72 had moderately impaired cognition, physical and verbal behaviors, required extensive assistance of two persons to transfer, did not walk, had a fall with fracture prior to admission, and had 1 fall with no injury since admission. A fall risk care plan dated 01/09/14 indicated Resident #72 was at risk for falls due to increased weakness and decrease in cognition. The goal was for the resident to have no falls for 90 days. Interventions were: "Gather and assess information on past falls; monitor and document signs/symptoms of adverse effects of medications; encourage to request assist in ambulating; clutter-free environment and articles of care within resident's reach; refer to therapy for evaluation as indicated for any (signs/symptoms) of decline; keep call light in reach and answer promptly; assist with transfers and ambulation as needed; and encourage resident to call for assistance as needed and report any signs of dizziness." A personal alarm care plan dated 01/09/14 indicated Resident #72 required use of a personal alarm. The goal was for the resident to have the personal safety alarm attached for the next 90 days. Interventions included: "Resident will have personal alarm attached to self and chair when up in chair; resident will have personal alarm attached to self and bed when in bed; respond immediately to alarm when it goes off..." An incident report dated 02/20/14 indicated Resident #72 got out of his geri chair without assistance and fell . The report noted, "Personal alarm went off, but no one was able to get to him before he fell ." A fall risk care plan dated 01/09/14 indicated a hand written notation dated 02/20/14 indicating Resident #72 had an actual fall on 02/20/14 "neuros started and are (within normal limits)." No new goals or interventions were noted. Behavior monitoring records dated March 2014 indicated Resident #72 had no behaviors documented and had no side effects from his quitiapine or [MEDICATION NAME]. An incident report completed by LVN A dated 03/12/14 indicted on 03/11/14 at 9:30 p.m., Resident #72 was "found by on coming nurse face down on floor in front of bathroom door. Blood observed on left arm, hand, and floor. Called for assistance. MD notified and resident sent to (local hospital) via ambulance." The activity at the time of the incident indicated he moved from his bed unassisted. The report also indicated there were no witnesses. The type of injury documented was a laceration to his left hand and arm. The supervisor investigation indicated there was "no change in mental status or physical function" and the report was signed by the DON and administrator on 03/13/14. A resident transfer form completed by LVN A dated 03/12/14 indicated on 03/11/14, no time indicated, Resident #72 was transferred to a local hospital. The reason for transfer was marked, bleeding other than GI (gastrointestinal), fall, and altered mental status/change in cognitive status. The last nursing note in Resident #72's clinical record was dated 03/11/14 at 3:48 p.m. and indicated he was "alert and responsive. Total assist with ADLs. No (signs/symptoms) of pain or discomfort noted." A hospital history and physical dated 03/12/14 indicated the chief complaint for Resident #72 was a fall. Examination of the head indicated periorbital hematoma (blood-filled bruising and swelling around the eye.) A CT (computed tomography) of his head indicated a subarachnoid hemorrhage (bleeding in his brain) and a neurosurgeon was consulted. A hospital discharge summary dated 03/24/14 indicated Resident #72 "was admitted to the hospital for a subarachnoid hemorrhage, status [REDACTED]." During an interview on 04/26/14 at 9:35 a.m., LVN A said he came in around 9:00 p.m. or 9:15 p.m. to get ready for his shift. When he walked in the door, he heard an alarm going off. He said he did not see any staff at the nursing station or in the halls. He first went down Hall A, and the alarm was not on that hall. He then started down Hall B, and the alarm was going off in Resident #72's room, the first room on the right. He said Resident #72 was lying "face down and unconscious." He said there was blood on the floor. He said he checked for a pulse and respirations and called out for help. He said he saw a contusion above the resident's eye. LVN A said LVN B arrived and took the resident's vital signs. LVN A said he then left and called the doctor for an order to transfer Resident #72 to the hospital. LVN A said he did not write any nursing notes. He said, "I guess I thought (LVN B) would do the the nurses' notes." During an interview on 04/26/14 at 10:05 a.m., LVN A said he called the physician to notify him of what happened. He was not sure how long it was between calling the physician and the ambulance arriving. LVN A said Resident #72 was "face down in front of the bathroom door. It looked like he hit his head on the table or the refrigerator as he fell . He was contorted, had a contusion over his eye, and there was blood on his arm. He was breathing and had a pulse." LVN A could not remember if the resident had any socks or shoes on. LVN A further stated, "When (LVN B) came in, she took his vital signs. I don't remember seeing any staff in any of the hallways when I got to work." LVN A said prior to this incident, Resident #72 had to be carefully watched because he would try to get out of his geri chair all the time when he was awake. He said Resident #72 usually had a pad alarm and a clip alarm because he would pull his clip alarm off. LVN A said when the resident was restless, they would bring him to the nursing station in his geri chair so they could watch him. LVN A said the hospital said the cause of Resident #72's death was bruising on the brain related to this injury. LVN A said the normal staffing for the 2:00 p.m. to 10:00 p.m. shift was 3 nurses and 6 CNAs. A staff sign-in assignment record dated 03/11/14 indicated there were 3 LVNs and 5 CNAs. During an interview on 04/26/14 at 3:55 p.m., CNA C said she put Resident #72 to bed with both his pad (bed) alarm and clip on alarm. She was not sure of the time. CNA C said the bed was in the low position and the door was open. She said she took his dirty linens out then went to the room next door to Resident #72 to assist that resident to bed. She said she was in that resident's room with the door closed. CNA C said she did not hear the alarm in Resident #72's room. CNA C said the first she knew of the incident was when LVN A came to get her for assistance. CNA C said it could not have been more than 10 minutes between putting Resident #72 to bed and LVN A asking for assistance. CNA C said Resident #72 was on the floor by the bathroom door and there was blood on the floor. She said the resident was not talking. She said the resident "came alert" when LVN A asked, "Are you hurt?" CNA C said Resident #72 responded, "I got to get up." CNA C said another nurse came in, but she did not remember who the nurse was. CNA C said Resident #72 did not usually try to get out of bed. She said when the resident was agitated, they would put him in a geri chair at the nursing station. CNA C said when the resident was in bed, they "checked on him a lot" because he was active. CNA C said the ambulance arrived a few minutes before 10:00 p.m. During an observation on 04/26/14 at 4:05 p.m., a surveyor stood in Resident #72's room with the door open and a second surveyor went in the room next door with the door closed. The surveyor separately set off both a pad (bed) alarm and a personal clip alarm in the room that had been Resident #72's. Both could clearly be heard from the next room. At 4:10 p.m., a surveyor stood at the entrance door. Both alarms could clearly be heard when set off. During an interview on 04/26/14 at 4:15 p.m., the treatment nurse said the alarms were always kept on the high setting. The back of the alarms had to be removed to change the setting. She said it could "definitely" be heard if you were in the room next door where an alarm was sounding and could be heard "from one end of the hall to the other." During an interview on 04/26/14 at 4:39 p.m., LVN B said she worked prn (as needed). She said she was in the hall at the opposite end of Hall B from Resident #72's room. She said a CNA, who she could not identify, hollered from Resident #72's room to get some gloves and come quickly. LVN B said she did not hear an alarm. When she came in the room, LVN A was with the resident. The resident was face down on the floor with his arm under him. LVN B said LVN A lifted the resident and got his arm from beneath him. LVN B said she could then see Resident #72 was bleeding from his arm or his hand and had a bruise developing over his eye. She said she applied pressure to his bleeding arm. LVN B said she did not recall the resident saying anything, but he was making some "noises." LVN B said she took Resident #72's vital signs and stated she "could not recall doing a whole lot." She stated, "I was afraid to move him much." She said the time of the incident was between 9:30 p.m. and 9:45 p.m. because she was finishing her medication pass. LVN B said she stayed with Resident #72 while LVN A left to make phone calls to get the resident transported to the ER. LVN A was not sure what time the ambulance arrived. She said she did not document anything about the incident in the nursing notes. LVN B said she thought LVN A did because he was more familiar with the documentation. LVN B said they usually kept Resident #72 in a geri chair at the nursing station where they could watch him more closely. LVN B stated, "We did not dare put the resident to bed before he got sleepy." LVN B said Resident #72 was sleepy earlier than usual that day and they put him to bed. LVN B said she should clearly hear an alarm sounding if she was in the hall. During an interview on 04/26/14 at 4:56 p.m., LVN D said she was the Hall A charge nurse the night of the incident with Resident #72. LVN D said she frequently worked Hall B as well and was familiar with Resident #72. LVN D said if she was down Hall A or if TVs were on loud, she would not hear an alarm on Hall B. LVN D said Resident #72 was very restless and repeatedly tried to get out of his geri chair. She said to keep him safe, she often had to take him in his geri chair down the hall with her so he could see her and she could talk to him. LVN D said she and the CNAs would take turns taking him with them on the hall. She said at times he was so active he required one-on-one supervision. 2. A face sheet dated 07/13/13 indicated Resident #5 was admitted [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Undated active physician orders [REDACTED].#5 included [DIAGNOSES REDACTED]. The orders included "Bed Alarm every shift" and "Chair alarm every shift", start date 03/05/14. The most recent MDS dated [DATE] indicated Resident #5 had falls since re-admission. Comprehensive Care Plan dated 02/21/14 for Resident #5 indicated the following: "Problem: "Resident at risk for falls related to history of falls, unsteadiness, weakness, [MEDICAL CONDITION], confusion, multiple meds, and other disease process." Goals: "Resident will be free of falls/injuries related to falls x 90 days." - Approaches: "Gather and assess information on past falls ...encourage to request assist in ambulating;...Refer to therapy;... Notify MD/Family of changes; ...Keep call light in reach and answer promptly." Handwritten updates under the "problems" column of the care plan indicated resident #5 had falls on 02/22/14, 02/26/14, 04/04/14 and 04/16/14 with no injuries. Handwritten updates under the "goals" column of the care plan indicated Resident #5 had falls on 03/06/14, 03/15/14, 03/16/14, 03/16/14, 03/25/14, 04/01/14 with no injury and fell on [DATE] obtaining a hematoma to back of head. Undated, handwritten "interventions" indicated: "Keep light on in room at all times; provide activities for redirection; monitor freq. for attempts to stand; continue to monitor and redirect; landing mat beside bed; personal safety alarm and bed alarm." Handwritten "interventions" dated 04/26/14 indicated to place mesh under w/c (wheelchair) cushion to keep cushion from sliding. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The incident reports indicated Resident #5 fell from her wheelchair on 01/02/14 at 11:45 a.m., 01/06/14 at 12:30 p.m., 01/06/14 at 4:00 p.m., 01/13/14 at 1:40 p.m., 01/28/14 at 12:30 p.m., 02/02/14 at 4:00 p.m., 02/05/14 at 1:00 p.m., 02/15/14 at 11:00 a.m., 02/20/14 at 7:00 a.m., 02/22/14 at 4:45 p.m. and 02/26/14 at 7:00 a.m. and did not sustain injuries from these falls. Each incident report had a "Follow-up/Implementation/Disposition" to continue use of personal safety alarm and an "Interdisciplinary Assessment/Intervention Checklist" reflecting a rehab screen was initiated and the care plan was revised. The incident reports beginning 03/06/14 indicated Resident #5 fell from her wheelchair on 03/06/14 at 9:00 a.m., 03/15/14 at 9:30 a.m., 03/16/14 at 6:45 p.m., 03/25/14 at 3:00 p.m., 04/01/14 at 5:10 p.m., 04/07/14 at 4:50 p.m., 04/09/14 at 9:15 a.m., 04/16/14 - 3:00 p.m. and 04/21/14 at 4:45 p.m., all without sustaining injuries except on 03/15/14, she obtained a 2X3 cm (centimeter) abrasion above left eyebrow and on 04/09/14 she obtained a 2 cm hematoma to the back of her head. Other "interventions/Implementations" on the incident reports beginning 03/06/14 were to continue to use chair alarms, activities and 1:1. Fall Risk Assessments for Resident #5 dated 02/05/14, 02/15/14, 02/20/14, 02/22/14, 02/26/14, 03/06/14 and 03/15/14 reflected a "high" fall risk. Resident #5's physical therapy "Resident Screening Form" dated 01/09/14 indicated the resident shows no change. Resident #5's therapy "Resident Screening Form" dated 02/07/14 indicated physical therapy was to evaluate and treat. Resident #5's therapy "Resident Screening Form" dated 03/10/14 indicated the resident was receiving physical therapy. Resident #5's "Therapy Screen" dated 04/16/14 and 04/21/14 indicated the resident showed no changes in abilities. Resident #5 was observed on 04/22/14 at 9:00 a.m., 04/23/14 at 9:20 a.m. and again at 9:35 a.m. in her wheelchair with the chair alarm attached. She was observed on 04/24/14 at 1:10 p.m. at the nurse's station and on 4/26/14 at 3:00 p.m. in the dining room playing bingo with the chair alarm attached. Staff was present each instance. During an interview on 4/26/14 at 6:37 p.m., the ADON said when a resident falls, the nurse was to assess the resident for injuries. If there was an injury, staff were to intervene to assure the resident was safe and comfortable. She said the DON and administrator should be notified if the injury was major. She said neurological checks and vital signs should be conducted every 15 minutes for four times, every 30 minutes for four times, every hour for four times and then every shift. She said the physician and family should be notified and the resident should continue to be assessed for further injury. She said an incident report should be completed and the fall should be documented in the nursing notes. She said the nurse should look at the fall assessment to see if it had been updated. The ADON said when the fall risk assessment was on paper, they were being completed. She said the care plan should be updated for new interventions and the fall should be documented on the 24 hour report. She said before they went to computerized medical records, (LG computer system) they would write a referral to physical therapy for screening. She said since going to computerized charting, physical therapy was supposed to be "triggered" automatically to screen when a fall occurred. She said the pharmacy consultant reviewed residents' medications monthly for possible medications which could be causing the resident to fall. There were no care plans presented addressing falls for Resident #5 for the period of 01/02/14 until 02/21/14. Care plans reflected only the listing of each fall and no revisions to the interventions until 04/26/14. The undated policy titled Abuse Prohibition Management Program indicated, "Our Facility will not condone resident abuse, neglect, or mistreatment... Prevention: 5. ...e. The assessment care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents...who require heavy nursing care and/or are totally dependent on staff...Procedures: Identification: 1. h. Neglect is...a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." A Falls and Fall Risk, Managing Policy and Procedure revised December 2007 indicated the following: "Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify apprpriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions...to try to minimize serous consequences of fallilng. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling... 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions... 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls." The administrator, corporate RN, and ADON were notified on 04/26/14 at 11:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 04/26/14 at 9:42 p.m. and included: "Alleged practice: The facility failed to prevent a resident from falling. Approaches: 1. Residents' EMR fall risk assessments will be reviewed to ensure one has been completed in the past 30 days by DON/designee. Fall assessments are completed upon admission, re-admission, quarterly and with any fall. 2. All residents with a Fall Risk Assessment score greater than 6 will be classified as being at high risk for falls and such residents' plans of care will be reviewed and updated to reflect that appropriate safety measures are implemented such as (non-skid socks, floor mat on floor, bed in low position, personal alarms). Safety measures will be monitored by charge nurses q (every) shift and documented on residents (sic) TAR. Initiated 4/26/14 completion 4/30/14. 3. Residents at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within the first 8 hours of admission by the Admitting Nurse. The DON/ADON's (sic) will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and accurate and appropriate interventions are observed in place. 5. Therapy will review any resident with a high risk fall assessment for interventions to prevent falls within 72 hours. 6. Licensed nurses in-serviced to notify the DON/designee of all falls within 30 minutes of the fall. The DON/designee will ensure a thorough assessment/appearance was completed and reported to the physician within 24 hours. 7. Staff will receive the fall prevention in-service by DON/designee initiated 4/26/14 completion 4/30/14 (see attached in-service). 8. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. The Interdisciplinary Team will review falls and significant changes in condition a the weekly Standards of Care meetings to ensure that the initiatives set forth in the plan are being met, along with compliance with other applicable facility protocols. 9. The QA/PI Committee will review falls and significant changes in condition and the effectiveness of this plan of removal at least monthly. The QA/PI Committee will be held monthly. 10. The plan will be revised after any fall to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. Care Plans Deficient Practice: Care plans were not reviewed/revised after each fall. Plan: 1. The plan of care will be reviewed after each fall in the morning meeting conducted by the DON/Admin. 2. Falls will be referred to the therapy department for screening within 72 hours. 3. A complete audit of all resident charts was conducted on 4/26/14 to ensure that Fall Risk Assessments had been completed within the last 30 days. The audit determined ALL residents had a Fall Risk Assessment completed. All residents with a Fall Risk Assessment score greater than 6 were classified as being at high risk for falls and such residents' plans of care were reviewed and updated to plan of care on 4/26/14. 4. Fall Risk Assessments for newly admitted residents will be completed within first 8 hours of admission by the Admitting Nurse. The DON or designee will review each new Admission Chart within 72 hours of admission to ensure Fall Risk Assessments are complete and develop a plan of care for the risk of falls. 5. Residents, at risk for falls, including residents with alarms, will be checked visually q 30 minutes by nurse aides and monitored q shift by charge nurses beginning 4/26/14. 6. The QAPI (sic) Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its (sic) initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are effective. Failure to Investigate 1. The charge nurse will initiate investigative process on incidents by obtaining statements from staff members and witnesses before end of shift. 2. The Charge Nurse will notify the Administrator and/or the DON of the incident to determine if the investigation should be called into the state agency within 24 hours. Nurses will be in serviced prior to beginning to next shift beginning 4/26/14 On-going. 3. DON/Administrator/RN Supervisor will review each incident within 24 hours. 4. Plans will be put into place to prevent other incidents from reoccurring (sic) (therapy, alarms, mats, etc) within 24 hours and monitored q shift. 5. Care Plans will be revised/updated by IDT (Interdisciplinary Team)/charge nurse to reflect the changes/new interventions within 24 hours. 6. In-service staff regarding new interventions put into place as implemented/needed by DON/designee within 24 hours beginning 4/26/14 completion 4/30/14. 7. The Interdisciplinary Team will review documentation and interventions related to incidents on a weekly basis and any issues identified in such review will be promptly addressed. On-going 8. The QA/PI Committee will review incident reports and documentation and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective. Assessment Deficient Practice: The nurse did not document an assessment of the resident when they were found on the floor. Plan: 1. The facility's policy and practice will be that it is mandatory for charge nurses to complete a Change of Condition form in addition to an Incident Report for every resident fall within one hour of fall. The Change of Condition Form prompts and documents comprehensive assessment of resident's condition and communication to the attending physician of the situation, background and assessment/appearance within 24 hours. 2. Charge nurses will be in-serviced on Change of Condition/Fall documentation prior to next shift by management nurses beginning 4/26/14. 3. DON/Administrator will review each incident report to ensure that an appropriate Change of Condition was completed and that the physician was notified timely of the resident's assessment/appearance and condition within 24 hours. Nurses found not to be in compliance will receive written counseling up to and including termination or further education as appropriate. 4. The DON and/or Administrator will be notified of any falls resulting in transfer to a hospital setting within 30 minutes. 5. The Interdisciplinary Team will review documentation, assessment and interventions related to falls on a weekly basis and any issues identified in such review will be promptly addressed. 6. The QA/PI Committee will review significant changes in condition and the effectiveness of this plan of removal at least monthly. The plan will be revised as needed to ensure the on-going effectiveness of the corrective measures and its initiatives outlined in providing quality care to residents in accordance with regulatory guidelines. The QA/PI Committee is responsible for the over-all monitoring and on-going evaluation of the Plan of Removal and making revisions if certain aspects of the plan are ineffective." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs were interviewed and were able to identify the risk factors that could lead to falls, ways to keep the environment safe, ways to assist residents who were at risk for falls, monitor residents who had a fall, and ways to prevent further falls should one occur, and how to monitor alarms were in place as ordered. Five LVNs and one RN were interviewed and were able to identify what documentation to do should a resident have a fall, who to notify, when to update care plans, when a fall risk assessment should be completed and within what time-frame, and when and how to initiate an investigation if a resident experienced a fall, and how to monitor that alarms were in place correctly. Fall risk assessments for 7 residents at high risk for falls were reviewed and the assessments had been updated as of 04/26/14. Care plans for 7 residents at high risk for falls were reviewed and the care plans had been updated as of 04/26/14. On 04/27/14 at 3:52 p.m., the administrator, corporate RN, and ADON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 04/27/14 at 4:30 p.m., the administrator indicated 54 residents were at risk for falls, 21 of those had alarms.

Based on observation, interview, and record review, the failed to implement interventions based on a comprehensive assessment to prevent development and worsening of pressure sores for 2 of 6 residents reviewed for pressure sores. (Resident #s 56 and 33) 1. Resident #56 had a history of [REDACTED].#56's buttocks, but no new interventions were put into place. Resident #56 had open areas on her buttocks on 4/22/14 (2 days later). No interventions were put into place after the areas opened until 4/23/14. 2. Resident #56 was noted to have bluish colored discoloration around the heel of her left ankle. The left heel area appeared mushy. Staff did not have an assessment of her heel documented nor were interventions put into place until surveyor intervention. 3. The facility did not float Resident #33's heels to prevent pressure. This failure could place 9 bedfast residents and 50 residents in a chair most of the time at risk for pressure sore development or worsening of existing pressure sores. Findings included: 1. Undated active physician orders [REDACTED]. Her orders included apply [MEDICATION NAME] ointment every shift to buttocks (3/05/14), apply [MEDICATION NAME] ointment as needed due to redness on buttocks (3/05/14), and Monday, Wednesday, and Friday daily at bedtime-[MEDICATION NAME] vaginal cream (3/31/14). There was no order for stress with zinc tablet, multivitamin with minerals tablet, or treatment orders for Resident #56's buttocks or left heel until 4/23/14 (after surveyor intervention). The most recent MDS (significant change) dated 4/15/14 indicated the following for Resident #56: *required extensive-total, one person assistance with most ADLs, *had impairment on both sides of her lower extremities, and *was always incontinent of bowel and bladder. Resident #56's care plans indicated the following: *11/25/13, potential for skin breakdown-buttocks. A handwritten undated note at the bottom of the page indicated "(resident) often scratches herself. (Resident) redirected." Approaches included "inspect and chart skin integrity every week & prn." *4/18/14, has chronic cognitive deficit; *4/18/14, extensive to total assistance with ADL care; *4/23/14, Resident had a stage 2 pressure sore to her left lower buttocks and left upper buttocks. Approaches included Resident was placed on an air mattress 4/23/14 (after surveyor intervention). A skin data report dated 4/14/14 indicated Resident #56 did not have any skin problems except bruises to her left leg/foot. A Braden scale assessment dated [DATE] indicated Resident #56 was moderate risk for pressure sores. Physician's telephone orders dated 4/23/14 at 18:45 (after surveyor intervention) indicated clean small open area to left upper and lower buttocks with normal saline, pat dry with gauze, apply [MEDICATION NAME] and clean dressing until healed. A wound report dated 4/17/14-4/24/14 indicated on 4/23/14 resident had: *one stage two pressure sore to her left upper buttocks measuring 1 centimeter (cm) X 0.7 cm, *one stage two pressure sore to her left lower buttocks measuring 0.5 cm X 0.5 cm. During observation and interview on 04/23/14 at 3:20 p.m., CNA S provided incontinent care for Resident #56. Resident #56 was on a regular mattress (not on any special low air loss mattress to prevent development or worsening of pressure sores). She turned the resident over and the resident was very reddened in her gluteal fold and anal area. Two small open areas were observed on the left sacral area with the entire area being dark red in color. Each open area was approximately 1.5 cm circular with white edges (did not have the appearance of scratches) and approximately 5 cm apart from each other. CNA S applied [MEDICATION NAME] cream to the open areas and entire coccyx/gluteal fold area. The resident made a slight movement and CNA S asked her if "that" hurt because she "flinched". CNA S said she would tell the nurse. During an observation and interview with CNA L on 4/24/14 at 1:16 p.m., Resident #56 was lying in her bed. She was on a low air loss mattress. CNA L stated, "this mattress is not right". Surveyor then observed the mattress was not turned on (CNA L did not notice the mattress was off). Surveyor noted a red area on the left inner thigh that looked like the imprint of a brief that had been secured too tight. CNA L said she did not know if the area was there earlier because she took over care of Resident # 56 when the aide assigned to her had to leave around 11:00 a.m. She agreed the imprint resembled a brief that had been secured too tight. CNA L turned Resident #56 over on her left side to perform care to the coccyx area. Surveyor noted an area on Resident #56's left gluteal fold appeared to be open (stage 2). Both areas on the gluteal folds were red. During an interview on 4/23/14 at 5 p.m., CNA S said the first day she saw anything on Resident #56's bottom was 3-4 days prior (approximately 4/20/14). She said she noticed redness on Resident #56's "butt cheeks." She said LVN O looked at Resident #56's buttocks and gave her cream in a tube to put on it. CNA S said it was a prescription cream, but not [MEDICATION NAME]. She said on the day prior (4/22/14), the same areas were open. She said LVN D told her it would be better to look at it with Resident #56 lying down. She said LVN D did not have them lie Resident #56 down and nothing else was said. She said LVN D just stayed at her computer. She said she placed [MEDICATION NAME] on her areas (including the open wounds). She said she did what she was told to do. She said she did not just want to leave it and do nothing. During an interview on 4/27/14 at 7:50 p.m., CNA S said she could not think of anything she did wrong, except put the cream on the open areas. She said she normally would have left it alone and knows better. During an interview on 4/23/14 at 5:35 p.m., CNA L said they normally applied [MEDICATION NAME] to open and reddened areas. She said if a treatment order was in place, they still applied [MEDICATION NAME] to open areas. Upon clarification, she repeated the same statement. During an interview on 4/24/14 at 9:15 a.m., LVN O said Resident #56 did not have any issues with her skin. She later said Resident #56 always had redness. She said Resident #56 had a prescription vaginal cream and [MEDICATION NAME]. She said CNAs were only given the [MEDICATION NAME] to apply. She said she was not aware of Resident #56 having any open areas. She said no open areas should have [MEDICATION NAME] applied to them. She said they had not had any in-services on wound care recently to her knowledge. During an interview on 4/23/14 at 6:05 p.m., LVN D said she had been a nurse since 2002 and had been working at the facility since 10/13. She said she worked A and B Hall split. LVN D said CNA S informed her of the redness to Resident #56's buttocks on 4/22/14. She said she was passing medications at the time and it took her approximately 45 minutes to look at her buttocks. She said Resident #56 had redness to her buttocks. She said they just applied [MEDICATION NAME] to her red areas. She said she did not know how long the redness had been on her buttocks. She said she looked at Resident #56's buttocks the previous day and the present day (4/23/14). She went on to say she looked at Resident #56's buttocks 30-40 minutes prior to the interview. She said there were no open areas the day prior (4/22/14), but now Resident #56 had open areas. She said she knew the staging of the pressure sores, but did not want to say because the treatment nurse staged the pressure sores. She went on to say the treatment nurse was in charge (indicating she was responsible for the staging and treatment of [REDACTED]. She said she was not aware the CNAs were placing [MEDICATION NAME] to open wounds. During an interview on 4/24/14 at 10:08 a.m., CNA U said she worked the previous weekend and did not see redness to Resident #56's buttock. During an interview on 4/23/14 at 6:45 p.m., the LVN/treatment nurse said she had been the treatment nurse at the facility for 5-6 months. She said CNA S told her 30 minutes prior about Resident #56's areas to her buttocks. She said she went in to assess Resident #56. She said she had two small open areas to her buttocks measuring 1 cm X 0.7cm and 0.5 cm X 0.5 cm. She said Resident #56 had one area to her right buttock which was blanchable (non-pressure sore) at the time. She said she notified the physician. She said the last skin assessment she conducted was on the previous Monday (4/14/14) and she did not have any areas to her buttocks. She said Resident #56 has had redness, but it had been blanchable. She went on to say Resident #56 scratched her buttocks and it had been care planned. During an interview on 4/23/14 at 6:38 p.m., ADON said CNAs were supposed to report skin changes to the charge nurse. She said the charge nurse was responsible for reporting to the treatment nurse. She said if the treatment nurse was not present, the charge nurse should assess the area and document it in the nursing notes. She said [MEDICATION NAME] should not be placed on an open wound. She said the nurses should not give any prescription cream to CNAs to apply to resident's skin. She said CNAs could apply protectant cream ([MEDICATION NAME]) only. She said she was not aware of Resident #56's areas until the treatment nurse told her on the present day. She said she called CNA T who said she did not see open areas to Resident #56's buttocks the present morning. She went on to say CNA T said Resident #56 scratches. She said she was not aware Resident #56 scratched until CNA T told her. She said red, blanchable areas should be on the skin assessment. She said the update date should be on the care plan when the care plan was updated. The last documented in-service provided on pressure sores was dated 12/2/13. The in-service training report did not have signatures in the allotted slots. An attached sheet titled "In-service 07/30/2012" had a line drawn through the 07/30/2012 and had a handwritten date next to it (12/2/13). The list was a typed employee list with signatures next to it. During an interview on 4/24/14 at 4:55 p.m., LVN W said the sign-in sheets which are attached to the in-service sheet had the date crossed out because the spreadsheet was used when they had meetings on payday and they could not get the date off the spreadsheet. The NPUAP web site at http://www.npuap.org/pr2.htm notes that in February 2007 the NPUAP redefined the definition of a pressure ulcer and the stages of pressure ulcers: Stage II pressure ulcer as "...partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough..." 2. During an observation on 4/24/14 at 1:16 p.m., Resident #56 was lying on a low air loss mattress. CNA L stated, "this mattress is not right". Surveyor then observed the mattress was not turned on (CNA L did not notice the mattress was off). CNA L removed the immobilizer to Resident #56's left leg. Surveyor noted a bluish colored discoloration around the heel of the left ankle. The left heel area appeared mushy. CNA L confirmed the area on Resident #56's left ankle looked discolored, but she did not know how long the area had been that way. Physician's telephone order dated 4/24/14 at 5:36 p.m., indicated every morning shift apply skin prep to left heel for preventative measures until resolved and apply skin prep to red blanchable area to left outer leg until resolved (after surveyor intervention). A treatment note dated 4/24/14 indicated Resident #56's brace was removed from left leg for assessment. A 1.5 cm X 1.5 cm slight pink-purple area was noted to left outer ankle. Her left heel also noted slightly boggy. Her brace was reapplied at this time. A new order was received to apply skin prep to both areas every day until resolved. Resident had stress with zinc, multivitamin with mineral and air mattress at the time (after surveyor intervention). During an interview on 4/24/14 at 10:11 a.m., the LVN/Treatment nurse said the DON went over staging with her and she had a book and a wound care consultant. She said she trained with the previous treatment nurse. She said she did not believe the DON had been in the room with her when conducting a skin assessment. She said the DON had been with her while staging and performing treatments. During an interview on 4/24/14 at 4:45 p.m., the treatment nurse said she saw the blueness around Resident #56's ankle and the heel was mushy, but she had not had time to document it yet. She said Resident #56 was placed on an air mattress the previous night (4/23/14). During an interview on 04/24/14 at 3:30 p.m., The ADON said Resident #56 was put on the air mattress on 04/24/14. She said they had air mattresses in the building already. 3. Undated active physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #33 had no pressure sores. A skin risk care plan updated 03/03/14 indicated Resident #33 was at risk for skin break down. The care plan did no address her darkened heels. During a skin observation on 04/25/14 at 4:35 p.m., Resident #33 had both heels resting directly on pillows. Her heels were not floated to remove pressure. CNA L said Resident #33's heels should not be resting on a pillow. CNA L moved Resident #33's pillows to behind her ankles so her heels were not resting on the bed or other surface. CNAs L and M turned and re-positioned the resident from side to side to aide in the skin assessment. When the assessment was completed, CNA L positioned Resident #33 on her back and placed both heels directly on the pillows.' An Evaluation policy and procedure dated 02/14 indicated "...evaluation of wounds will be performed... weekly and on discovery... Objective evaluation components include: A. Location B. Measurement C. Appearance D. Drainage E. Odor F. Presence of undermining/tunneling G. Healing H. Stage of a pressure ulcer I. Pain J. [MEDICAL CONDITION]" A Wound Documentation policy and procedure dated 04/12 indicated "...Documentation of wounds will be performed consistently... 1. ...Documentation about the wound provides valuable information about wound progress or lack of progress. 2. On... discovery, the clinician initiates the wound document process..." The CMS 672 dated 4/22/14 indicated 9 residents were bedfast and 50 residents were in a chair most of the time.

Based on interview and record review, the facility failed to implement their written policy and procedure that prohibited neglect in reporting labs and diagnostic test results for 1 of 4 residents reviewed for laboratory monitoring. (Resident #35) The facility failed to notify the physician of Resident #35's laboratory panic level values regarding [MEDICATION NAME] (blood thinner) therapy which created a delay in care, another administration of [MEDICATION NAME], and increased severity of a critical condition. He was hospitalized in the Intensive Care Unit with [MEDICAL CONDITION] and [MEDICAL CONDITION]. He was placed on a ventilator and given a blood transfusion. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/16/12. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Failure to ensure recognition and physician notification of panic lab values regarding anticoagulation therapy was likely to have caused the exacerbation of a [MEDICAL CONDITION] and resultant hospitalization of Resident #35 and could place the 10 residents receiving [MEDICATION NAME] at risk of delayed medical evaluation, harmful medical side effects, hospitalization , or death. Findings Included: A policy and procedure dated April 2007 and titled lab and diagnostic test results clinical protocol read, "Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: ...3. The resident's clinical status is unclear or worsening. 4. High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician..." The policy also indicated direct voice communication is the preferred way of informing the physician of any lab results requiring immediate notification. The policy also read if the physician does not respond to the immediate notification within an hour, the nursing staff should contact the medical director for assistance. A policy and procedure dated April 2007 and titled adverse consequences and medication related problems read, "The facility evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include an adverse drug reaction and side effects." An undated policy and procedure titled abuse prohibition read "The facility will not condone resident abuse, neglect or mistreatment or misappropriation of resident property by anyone, including staff members, other residents etc..." Physician orders [REDACTED]. Resident #35's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. an order for [REDACTED]. The quarterly MDS dated [DATE] indicated Resident #35 was moderately cognitively impaired and required extensive assistance for ADLs. A plan of care for Resident #35 dated 4/1/12 read to perform labs as ordered by MD and report abnormal values to MD. A lab result for Resident #35 dated 5/7/12 read "PANIC". The lab phoned the abnormal results to LVN D at 10:59 a.m. The results were PT of 54.70 (normal range 9.45-13 seconds) and INR 4.90 (normal range 2-3 seconds). Mosby Dictionary of Medicine, 7th edition 2006, defines PT ([MEDICATION NAME] time) as the amount of time required for the blood to clot (prevent free bleeding). The Mosby Dictionary of Medicine, 7th edition 2006, defines INR as a rating of a patient's PT ratio, used as a standard for monitoring the effects of [MEDICATION NAME]. A nursing note for Resident #35 by LVN D dated 5/7/12 at 11:00 a.m. indicated PT/INR panic values were phoned by the lab services, and Resident #35's physician was notified. No other notes that pertained to lab values were in the clinical record for that shift. During an interview on 5/15/12 at approximately 12:45 p.m., LVN D said she called the physician's office regarding the panic lab results for Resident #35 and did not know who she talked to, but she let them know she was faxing it. LVN D said she did not follow up with the lab results, but passed it in report to the next nurse. A nursing note for Resident #35 for the next shift (2-10) dated 5/7/12 and timed 9:00 p.m. had one entry by LVN E that made no mention of the panic laboratory values. Resident #35's May 2012 MAR indicated [REDACTED]. During an interview on 5/15/12 at 2:15 p.m., LVN E said she was told in report about the critical lab value for Resident #35, and the doctor was faxed. She said she did not try to call again and gave the next dose of [MEDICATION NAME] since there were no new orders. She further said the fax machine was broken during her shift and not fixed until the next day. A nursing note for Resident #35 for the next shift (10-6) dated 5/8/12 and untimed had one entry by LVN F that made no mention of the panic laboratory values. During an interview on 5/15/12 at 2:58 p.m., LVN F said the laboratory results for Resident #35 were faxed to the doctor and she did not look at the results or notify the physician because the shift before her had taken care of that. A nursing note dated 5/8/12 at 11:00 a.m. by LVN G indicated that Resident #35 complained of nausea. The FNP was in the facility to examine the resident and new orders were received. The note did not mention the panic PT/INR result. Physician telephone orders for Resident #35 dated 5/8/12 regarding the 11:00 a.m. nursing note and the resident's complaint of nausea read, "1) 3 view of abdomen: regarding abdominal pain, 3) SSE daily times 3 days, 3) CBC, CMP, UA, amylase and lipase." (www.labtestsonline.org accessed 5/22/12 indicated amylase and lipase are tests to determine pancreatitis, inflammation of the pancreas.) A nursing note for Resident #35 dated 5/8/12 at 1:45 p.m. by LVN G indicated there was still no response from MD office regarding panic PT/INR. LVN G called the office and received an order to hold the [MEDICATION NAME] for 2 days and then decrease the dose to 4 mg every day. That was 26 hours and 45 minutes since first receipt of the panic lab values. During an interview on 5/15/12 at 11:50 a.m., LVN G said she did not know about Resident #35's panic lab results until 5/8/12 at approximately 1:45 p.m. when she called the office to get new orders since the lab values had not been addressed. A physician's telephone order for Resident #35 dated 5/8/12 related to LVN G's phone conversation about panic lab values read, "1) hold [MEDICATION NAME] for 2 days, 2) decrease [MEDICATION NAME] to 4 mg by mouth every day, 3) PT/INR in one week." An abdominal x-ray report for Resident #35 dated 5/8/12 and faxed to the facility at 9:59 p.m. read, "Impression: "1) Distention of the colon between the right colon and mid descending colon. There is no sigmoid nor rectal air, therefore early colon obstruction versus ileus must be clarified. 2) Follow-up recommended." A nursing note for Resident #35 dated 5/9/12 at 4:30 a.m. had an entry that read the resident was hollering and complained of abdominal pain. At that same time, the abdominal x-ray results were faxed to the physician's office. A nursing note for Resident #35 dated 5/9/12 at 6:10 a.m. indicated the resident was yelling out with complaints of abdominal pain. The resident's abdomen was distended. The ADON and FNP were notified of the change in condition, elevated BP, and abdominal x-rays. Orders were received to send the Resident #35 to the local ER for evaluation and treatment. At 7:15 a.m., EMS arrived to transport Resident #35. A May 2012 anticoagulation monitoring sheet for Resident #35 indicated no symptoms abdominal pain or nausea present on 5/7/12, 5/8/12, or 5/9/12 for all nursing shifts. During an interview on 5/15/12 at 12:10 p.m., Resident #35's FNP said she was at the facility on 5/8/12 around 11:00 a.m. The FNP said her first knowledge of the panic PT/INR was on 5/8/12 around 2:00 p.m. when the facility called the office and the orders were given to hold the [MEDICATION NAME] for 2 days. The history and physical report, with a dictation date of 5/9/12, received from the admitting hospital for Resident #35 noted the resident was transferred from another local hospital on [DATE] where the chief complaint was abdominal pain. Resident #35 was intubated due to [MEDICAL CONDITION]. Resident #35's hemoglobin was 4.5 (normal range 13.5-18 g/dL in men) and INR was 4.9 (normal range 2-3 seconds) at the transferring hospital. During admission, further labs included a PT of 55.7 (normal range 9.45-13 seconds), INR of 5.0 (normal range 2-3 seconds), and hemoglobin of 4.5 (normal range 13.5-18 g/dL in men). The assessment and plan read Resident #35 was admitted with [MEDICAL CONDITION] and placed on a mechanical ventilator. The resident also had symptomatic [MEDICAL CONDITION] and received a transfusion of 4 packs of red blood cells. The report indicated the resident was taking [MEDICATION NAME], but the physician at the hospital was unsure why the resident was receiving it. The attending physician ordered to give fractioned plasma and vitamin K to reverse the INR. Resident #35's condition was listed as critical and he was admitted to the Intensive Care Unit. Mosby's Dictionary of Medicine, 7th edition 2006, defines hemoglobin as complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs. During the hospital admission on 5/10/12, Resident #35 had a esophagogastroduodenoscopy (a endoscopic test that permits direct visualization of the upper gastro-intestinal tract) with biopsy and colonoscopy. The post-operative [DIAGNOSES REDACTED]. During an interview on 5/15/12 at 3:20 p.m., the attending physician for Resident #35 said the resident was admitted with a [MEDICAL CONDITION] with [MEDICAL CONDITION] and giving the 5/7/12 [MEDICATION NAME] 5 mg dose after the panic labs were received only exacerbated his condition. During an interview on 5/15/12 at 3:00 p.m., LVN C said the physician should have been called regarding the panic level PT/INR for Resident #35 and if no response, the nurse should have called again. During an interview on 5/15/12 at 3:08 p.m., the DON said the physician should have been contacted regarding the PT/INR level and the medication held until new orders were received. During an interview on 5/15/12 at 3:55 p.m., the corporate nurse said she could see where the facility "dropped the ball" regarding Resident #35. The administrator and DON were notified on 5/15/12 at 3:55 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/12 at approximately 5:20 p.m. and included: "1) All residents receiving [MEDICATION NAME] and additional anti-coagulations charts and labs have been reviewed to ensure PT/INR parameters are within acceptable limits. 2) All licensed nursing staff will be in-serviced regarding policy and procedure for panic lab values beginning on 5/15/12 and will be ongoing. 3) In addition to immediate notification to the physician, all panic lab values will be reported to the DON and administrator upon receipt. 4) In the event that the attending physician does not respond within two hours the medical director will be contacted. 5) Anticoagulation therapy monitoring log is currently in the MAR for each Resident receiving anticoagulation medication and assessed every shift." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: An in-service was performed with nursing staff to include: Critical lab monitoring, notification of physician, DON and administrator, information on lab resolution form, location of lab resolution form (steps to take when critical lab value identified), and what the nurse's documentation must include. Documentation of all residents who were on anticoagulation therapy charts reviewed for monitoring and lab values. Documentation received of anticoagulation sheets in place regarding the 10 residents currently taking [MEDICATION NAME]. Five nurses were interviewed regarding the recognition of panic lab values and the notification to the physician. Five of 5 nurses were able to identify the process in place and the new critical lab resolution form with the steps to take in notification and resolution. On 5/16/12 at 2:40 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 5/15/12 at 3:10 p.m., the DON said 10 residents were taking [MEDICATION NAME].

Based on interview and record review, the facility failed to implement their written policy and procedure that prohibited neglect in reporting labs and diagnostic test results for 1 of 4 residents reviewed for laboratory monitoring. (Resident #35) The facility failed to notify the physician of Resident #35's laboratory panic level values regarding [MEDICATION NAME] (blood thinner) therapy which created a delay in care, another administration of [MEDICATION NAME], and increased severity of a critical condition. He was hospitalized in the Intensive Care Unit with [MEDICAL CONDITION] and [MEDICAL CONDITION]. He was placed on a ventilator and given a blood transfusion. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/16/12. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Failure to ensure recognition and physician notification of panic lab values regarding anticoagulation therapy was likely to have exacerbated a [MEDICAL CONDITION] and resultant hospitalization of Resident #35 and could place the 10 residents receiving [MEDICATION NAME] at risk of delayed medical evaluation, harmful medical side effects, hospitalization , or death. Findings Included: Physician orders [REDACTED]. Resident #35's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. an order for [REDACTED]. The quarterly MDS dated [DATE] indicated Resident #35 was moderately cognitively impaired and required extensive assistance for ADLs. A plan of care for Resident #35 dated 4/1/12 read to perform labs as ordered by MD and report abnormal values to MD. A lab result for Resident #35 dated 5/7/12 read "PANIC". The lab phoned the abnormal results to LVN D at 10:59 a.m. The results were PT of 54.70 (normal range 9.45-13 seconds) and INR 4.90 (normal range 2-3 seconds). Mosby Dictionary of Medicine, 7th edition 2006, defines PT ([MEDICATION NAME] time) as the amount of time required for the blood to clot (prevent free bleeding). The Mosby Dictionary of Medicine, 7th edition 2006, defines INR as a rating of a patient's PT ratio, used as a standard for monitoring the effects of [MEDICATION NAME]. A nursing note for Resident #35 by LVN D dated 5/7/12 at 11:00 a.m. indicated PT/INR panic values were phoned by the lab services, and Resident #35's physician was notified. No other notes that pertained to lab values were in the clinical record for that shift. During an interview on 5/15/12 at approximately 12:45 p.m., LVN D said she called the physician's office regarding the panic lab results for Resident #35 and did not know who she talked to, but she let them know she was faxing it. LVN D said she did not follow up with the lab results, but passed it in report to the next nurse. A nursing note for Resident #35 for the next shift (2-10) dated 5/7/12 and timed 9:00 p.m. had one entry by LVN E that made no mention of the panic laboratory values. Resident #35's May 2012 MAR indicated [REDACTED]. During an interview on 5/15/12 at 2:15 p.m., LVN E said she was told in report about the critical lab value for Resident #35, and the doctor was faxed. She said she did not try to call again and gave the next dose of [MEDICATION NAME] since there were no new orders. She further said the fax machine was broken during her shift and not fixed until the next day. A nursing note for Resident #35 for the next shift (10-6) dated 5/8/12 and untimed had one entry by LVN F that made no mention of the panic laboratory values. During an interview on 5/15/12 at 2:58 p.m., LVN F said the laboratory results for Resident #35 were faxed to the doctor and she did not look at the results or notify the physician because the shift before her had taken care of that. A nursing note dated 5/8/12 at 11:00 a.m. by LVN G indicated that Resident #35 complained of nausea. The FNP was in the facility to examine the resident and new orders were received. The note did not mention the panic PT/INR result. Physician telephone orders for Resident #35 dated 5/8/12 regarding the 11:00 a.m. nursing note and the resident's complaint of nausea read, "1) 3 view of abdomen: regarding abdominal pain, 3) SSE daily times 3 days, 3) CBC, CMP, UA, amylase and lipase." (www.labtestsonline.org accessed 5/22/12 indicated amylase and lipase are tests to determine pancreatitis, inflammation of the pancreas.) A nursing note for Resident #35 dated 5/8/12 at 1:45 p.m. by LVN G indicated there was still no response from MD office regarding panic PT/INR. LVN G called the office and received an order to hold the [MEDICATION NAME] for 2 days and then decrease the dose to 4 mg every day. That was 26 hours and 45 minutes since first receipt of the panic lab values. During an interview on 5/15/12 at 11:50 a.m., LVN G said she did not know about Resident #35's panic lab results until 5/8/12 at approximately 1:45 p.m. when she called the office to get new orders since the lab values had not been addressed. A physician's telephone order for Resident #35 dated 5/8/12 related to LVN G's phone conversation about panic lab values read, "1) hold [MEDICATION NAME] for 2 days, 2) decrease [MEDICATION NAME] to 4 mg by mouth every day, 3) PT/INR in one week." An abdominal x-ray report for Resident #35 dated 5/8/12 and faxed to the facility at 9:59 p.m. read, "Impression: "1) Distention of the colon between the right colon and mid descending colon. There is no sigmoid nor rectal air, therefore early colon obstruction versus ileus must be clarified. 2) Follow-up recommended." A nursing note for Resident #35 dated 5/9/12 at 4:30 a.m. had an entry that read the resident was hollering and complained of abdominal pain. At that same time, the abdominal x-ray results were faxed to the physician's office. A nursing note for Resident #35 dated 5/9/12 at 6:10 a.m. indicated the resident was yelling out with complaints of abdominal pain. The resident's abdomen was distended. The ADON and FNP were notified of the change in condition, elevated BP, and abdominal x-rays. Orders were received to send the Resident #35 to the local ER for evaluation and treatment. At 7:15 a.m., EMS arrived to transport Resident #35. A May 2012 anticoagulation monitoring sheet for Resident #35 indicated no symptoms abdominal pain or nausea present on 5/7/12, 5/8/12, or 5/9/12 for all nursing shifts. During an interview on 5/15/12 at 12:10 p.m., Resident #35's FNP said she was at the facility on 5/8/12 around 11:00 a.m. The FNP said her first knowledge of the panic PT/INR was on 5/8/12 around 2:00 p.m. when the facility called the office and the orders were given to hold the [MEDICATION NAME] for 2 days. The history and physical report, with a dictation date of 5/9/12, received from the admitting hospital for Resident #35 noted the resident was transferred from another local hospital on [DATE] where the chief complaint was abdominal pain. Resident #35 was intubated due to [MEDICAL CONDITION]. Resident #35's hemoglobin was 4.5 (normal range 13.5-18 g/dL in men) and INR was 4.9 (normal range 2-3 seconds) at the transferring hospital. During admission, further labs included a PT of 55.7 (normal range 9.45-13 seconds), INR of 5.0 (normal range 2-3 seconds), and hemoglobin of 4.5 (normal range 13.5-18 g/dL in men). The assessment and plan read Resident #35 was admitted with [MEDICAL CONDITION] and placed on a mechanical ventilator. The resident also had symptomatic [MEDICAL CONDITION] and received a transfusion of 4 packs of red blood cells. The report indicated the resident was taking [MEDICATION NAME], but the physician at the hospital was unsure why the resident was receiving it. The attending physician ordered to give fractioned plasma and vitamin K to reverse the INR. Resident #35's condition was listed as critical and he was admitted to the Intensive Care Unit. Mosby's Dictionary of Medicine, 7th edition 2006, defines hemoglobin as complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs. During the hospital admission on 5/10/12, Resident #35 had a esophagogastroduodenoscopy (a endoscopic test that permits direct visualization of the upper gastro-intestinal tract) with biopsy and colonoscopy. The post-operative [DIAGNOSES REDACTED]. During an interview on 5/15/12 at 3:20 p.m., the attending physician for Resident #35 said the resident was admitted with a [MEDICAL CONDITION] with [MEDICAL CONDITION] and giving the 5/7/12 [MEDICATION NAME] 5 mg dose after the panic labs were received only exacerbated his condition. During an interview on 5/15/12 at 3:00 p.m., LVN C said the physician should have been called regarding the panic level PT/INR for Resident #35 and if no response, the nurse should have called again. During an interview on 5/15/12 at 3:08 p.m., the DON said the physician should have been contacted regarding the PT/INR level and the medication held until new orders were received. During an interview on 5/15/12 at 3:55 p.m., the corporate nurse said she could see where the facility "dropped the ball" regarding Resident #35. A policy and procedure dated April 2007 and titled lab and diagnostic test results clinical protocol read, "Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: ...3. The resident's clinical status is unclear or worsening. 4. High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician..." The policy also indicated direct voice communication is the preferred way of informing the physician of any lab results requiring immediate notification. The policy also read if the physician does not respond to the immediate notification within an hour, the nursing staff should contact the medical director for assistance. A policy and procedure dated April 2007 and titled adverse consequences and medication related problems read, "The facility evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include an adverse drug reaction and side effects." An undated policy and procedure titled abuse prohibition read "The facility will not condone resident abuse, neglect or mistreatment or misappropriation of resident property by anyone, including staff members, other residents etc..." The administrator and DON were notified on 5/15/12 at 3:55 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/12 at approximately 5:20 p.m. and included: "1) All residents receiving [MEDICATION NAME] and additional anti-coagulations charts and labs have been reviewed to ensure PT/INR parameters are within acceptable limits. 2) All licensed nursing staff will be in-serviced regarding policy and procedure for panic lab values beginning on 5/15/12 and will be ongoing. 3) In addition to immediate notification to the physician, all panic lab values will be reported to the DON and administrator upon receipt. 4) In the event that the attending physician does not respond within two hours the medical director will be contacted. 5) Anticoagulation therapy monitoring log is currently in the MAR for each Resident receiving anticoagulation medication and assessed every shift." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: An in-service was performed with nursing staff to include: Critical lab monitoring, notification of physician, DON and administrator, information on lab resolution form, location of lab resolution form (steps to take when critical lab value identified), and what the nurse's documentation must include. Documentation of all residents who were on anticoagulation therapy charts reviewed for monitoring and lab values. Documentation received of anticoagulation sheets in place regarding the 10 residents currently taking [MEDICATION NAME]. Five nurses were interviewed regarding the recognition of panic lab values and the notification to the physician. Five of 5 nurses were able to identify the process in place and the new critical lab resolution form with the steps to take in notification and resolution. On 5/16/12 at 2:40 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 5/15/12 at 3:10 p.m., the DON said 10 residents were taking [MEDICATION NAME].

Based on interview and record review, the facility failed to ensure [MEDICATION NAME] (blood thinner) was adequately monitored and not used in excessive dosage for 1 of 4 residents reviewed for [MEDICATION NAME] drug therapy. (Resident #35) The facility failed to notify the physician of Resident #35's laboratory panic level values regarding [MEDICATION NAME] therapy which created a delay in care, another administration of [MEDICATION NAME], and increased severity of a critical condition. He was hospitalized in the Intensive Care Unit with [MEDICAL CONDITION] and [MEDICAL CONDITION]. He was placed on a ventilator and given a blood transfusion. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/16/12. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Failure to ensure recognition and physician notification of panic lab values regarding anticoagulation therapy was likely to have caused the exacerbation of a [MEDICAL CONDITION] and resultant hospitalization of Resident #35 and could place the 10 residents receiving [MEDICATION NAME] at risk of delayed medical evaluation, harmful medical side effects, hospitalization , or death. Findings included: Physician orders [REDACTED]. Resident #35's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. an order for [REDACTED]. The quarterly MDS dated [DATE] indicated Resident #35 was moderately cognitively impaired and required extensive assistance for ADLs. A plan of care for Resident #35 dated 4/1/12 read to perform labs as ordered by MD and report abnormal values to MD. A lab result for Resident #35 dated 5/7/12 read "PANIC". The lab phoned the abnormal results to LVN D at 10:59 a.m. The results were PT of 54.70 (normal range 9.45-13 seconds) and INR 4.90 (normal range 2-3 seconds). Mosby Dictionary of Medicine, 7th edition 2006, defines PT ([MEDICATION NAME] time) as the amount of time required for the blood to clot (prevent free bleeding). The Mosby Dictionary of Medicine, 7th edition 2006, defines INR as a rating of a patient's PT ratio, used as a standard for monitoring the effects of [MEDICATION NAME]. A nursing note for Resident #35 by LVN D dated 5/7/12 at 11:00 a.m. indicated PT/INR panic values were phoned by the lab services, and Resident #35's physician was notified. No other notes that pertained to lab values were in the clinical record for that shift. During an interview on 5/15/12 at approximately 12:45 p.m., LVN D said she called the physician's office regarding the panic lab results for Resident #35 and did not know who she talked to, but she let them know she was faxing it. LVN D said she did not follow up with the lab results, but passed it in report to the next nurse. A nursing note for Resident #35 for the next shift (2-10) dated 5/7/12 and timed 9:00 p.m. had one entry by LVN E that made no mention of the panic laboratory values. Resident #35's May 2012 MAR indicated [REDACTED]. During an interview on 5/15/12 at 2:15 p.m., LVN E said she was told in report about the critical lab value for Resident #35, and the doctor was faxed. She said she did not try to call again and gave the next dose of [MEDICATION NAME] since there were no new orders. She further said the fax machine was broken during her shift and not fixed until the next day. A nursing note for Resident #35 for the next shift (10-6) dated 5/8/12 and untimed had one entry by LVN F that made no mention of the panic laboratory values. During an interview on 5/15/12 at 2:58 p.m., LVN F said the laboratory results for Resident #35 were faxed to the doctor and she did not look at the results or notify the physician because the shift before her had taken care of that. A nursing note dated 5/8/12 at 11:00 a.m. by LVN G indicated that Resident #35 complained of nausea. The FNP was in the facility to examine the resident and new orders were received. The note did not mention the panic PT/INR result. Physician telephone orders for Resident #35 dated 5/8/12 regarding the 11:00 a.m. nursing note and the resident's complaint of nausea read, "1) 3 view of abdomen: regarding abdominal pain, 3) SSE daily times 3 days, 3) CBC, CMP, UA, amylase and lipase." (www.labtestsonline.org accessed 5/22/12 indicated amylase and lipase are tests to determine pancreatitis, inflammation of the pancreas.) A nursing note for Resident #35 dated 5/8/12 at 1:45 p.m. by LVN G indicated there was still no response from MD office regarding panic PT/INR. LVN G called the office and received an order to hold the [MEDICATION NAME] for 2 days and then decrease the dose to 4 mg every day. That was 26 hours and 45 minutes since first receipt of the panic lab values. During an interview on 5/15/12 at 11:50 a.m., LVN G said she did not know about Resident #35's panic lab results until 5/8/12 at approximately 1:45 p.m. when she called the office to get new orders since the lab values had not been addressed. A physician's telephone order for Resident #35 dated 5/8/12 related to LVN G's phone conversation about panic lab values read, "1) hold [MEDICATION NAME] for 2 days, 2) decrease [MEDICATION NAME] to 4 mg by mouth every day, 3) PT/INR in one week." An abdominal x-ray report for Resident #35 dated 5/8/12 and faxed to the facility at 9:59 p.m. read, "Impression: "1) Distention of the colon between the right colon and mid descending colon. There is no sigmoid nor rectal air, therefore early colon obstruction versus ileus must be clarified. 2) Follow-up recommended." A nursing note for Resident #35 dated 5/9/12 at 4:30 a.m. had an entry that read the resident was hollering and complained of abdominal pain. At that same time, the abdominal x-ray results were faxed to the physician's office. A nursing note for Resident #35 dated 5/9/12 at 6:10 a.m. indicated the resident was yelling out with complaints of abdominal pain. The resident's abdomen was distended. The ADON and FNP were notified of the change in condition, elevated BP, and abdominal x-rays. Orders were received to send the Resident #35 to the local ER for evaluation and treatment. At 7:15 a.m., EMS arrived to transport Resident #35. A May 2012 anticoagulation monitoring sheet for Resident #35 indicated no symptoms abdominal pain or nausea present on 5/7/12, 5/8/12, or 5/9/12 for all nursing shifts. During an interview on 5/15/12 at 12:10 p.m., Resident #35's FNP said she was at the facility on 5/8/12 around 11:00 a.m. The FNP said her first knowledge of the panic PT/INR was on 5/8/12 around 2:00 p.m. when the facility called the office and the orders were given to hold the [MEDICATION NAME] for 2 days. The history and physical report, with a dictation date of 5/9/12, received from the admitting hospital for Resident #35 noted the resident was transferred from another local hospital on [DATE] where the chief complaint was abdominal pain. Resident #35 was intubated due to [MEDICAL CONDITION]. Resident #35's hemoglobin was 4.5 (normal range 13.5-18 g/dL in men) and INR was 4.9 (normal range 2-3 seconds) at the transferring hospital. During admission, further labs included a PT of 55.7 (normal range 9.45-13 seconds), INR of 5.0 (normal range 2-3 seconds), and hemoglobin of 4.5 (normal range 13.5-18 g/dL in men). The assessment and plan read Resident #35 was admitted with [MEDICAL CONDITION] and placed on a mechanical ventilator. The resident also had symptomatic [MEDICAL CONDITION] and received a transfusion of 4 packs of red blood cells. The report indicated the resident was taking [MEDICATION NAME], but the physician at the hospital was unsure why the resident was receiving it. The attending physician ordered to give fractioned plasma and vitamin K to reverse the INR. Resident #35's condition was listed as critical and he was admitted to the Intensive Care Unit. Mosby's Dictionary of Medicine, 7th edition 2006, defines hemoglobin as complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs. During the hospital admission on 5/10/12, Resident #35 had a esophagogastroduodenoscopy (a endoscopic test that permits direct visualization of the upper gastro-intestinal tract) with biopsy and colonoscopy. The post-operative [DIAGNOSES REDACTED]. During an interview on 5/15/12 at 3:20 p.m., the attending physician for Resident #35 said the resident was admitted with a [MEDICAL CONDITION] with [MEDICAL CONDITION] and giving the 5/7/12 [MEDICATION NAME] 5 mg dose after the panic labs were received only exacerbated his condition. During an interview on 5/15/12 at 3:00 p.m., LVN C said the physician should have been called regarding the panic level PT/INR for Resident #35 and if no response, the nurse should have called again. During an interview on 5/15/12 at 3:08 p.m., the DON said the physician should have been contacted regarding the PT/INR level and the medication held until new orders were received. During an interview on 5/15/12 at 3:55 p.m., the corporate nurse said she could see where the facility "dropped the ball" regarding Resident #35. The administrator and DON were notified on 5/15/12 at 3:55 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/12 at approximately 5:20 p.m. and included: "1) All residents receiving [MEDICATION NAME] and additional anti-coagulations charts and labs have been reviewed to ensure PT/INR parameters are within acceptable limits. 2) All licensed nursing staff will be in-serviced regarding policy and procedure for panic lab values beginning on 5/15/12 and will be ongoing. 3) In addition to immediate notification to the physician, all panic lab values will be reported to the DON and administrator upon receipt. 4) In the event that the attending physician does not respond within two hours the medical director will be contacted. 5) Anticoagulation therapy monitoring log is currently in the MAR for each Resident receiving anticoagulation medication and assessed every shift." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: An in-service was performed with nursing staff to include: Critical lab monitoring, notification of physician, DON and administrator, information on lab resolution form, location of lab resolution form (steps to take when critical lab value identified), and what the nurse's documentation must include. Documentation of all residents who were on anticoagulation therapy charts reviewed for monitoring and lab values. Documentation received of anticoagulation sheets in place regarding the 10 residents currently taking [MEDICATION NAME]. Five nurses were interviewed regarding the recognition of panic lab values and the notification to the physician. Five of 5 nurses were able to identify the process in place and the new critical lab resolution form with the steps to take in notification and resolution. On 5/16/12 at 2:40 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 5/15/12 at 3:10 p.m., the DON said 10 residents were taking [MEDICATION NAME].

Based on record review and interview, the facility failed to notify the physician regarding critical lab values for 1 of 4 residents reviewed for laboratory monitoring. (Resident #35) The facility failed to notify the physician of Resident #35's laboratory panic level values regarding [MEDICATION NAME] (blood thinner) therapy which created a delay in care, another administration of [MEDICATION NAME], and increased severity of a critical condition. He was hospitalized in the Intensive Care Unit with [MEDICAL CONDITION] and [MEDICAL CONDITION]. He was placed on a ventilator and given a blood transfusion. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 5/16/12. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Failure to ensure recognition and physician notification of panic lab values regarding anticoagulation therapy was likely to have caused the exacerbation of a [MEDICAL CONDITION] and resultant hospitalization of Resident #35 and could place the 10 residents receiving [MEDICATION NAME] at risk of delayed medical evaluation, harmful medical side effects, hospitalization , or death. Findings included: Physician orders [REDACTED]. Resident #35's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. an order for [REDACTED]. The quarterly MDS dated [DATE] indicated Resident #35 was moderately cognitively impaired and required extensive assistance for ADLs. A plan of care for Resident #35 dated 4/1/12 read to perform labs as ordered by MD and report abnormal values to MD. A lab result for Resident #35 dated 5/7/12 read "PANIC". The lab phoned the abnormal results to LVN D at 10:59 a.m. The results were PT of 54.70 (normal range 9.45-13 seconds) and INR 4.90 (normal range 2-3 seconds). Mosby Dictionary of Medicine, 7th edition 2006, defines PT ([MEDICATION NAME] time) as the amount of time required for the blood to clot (prevent free bleeding). The Mosby Dictionary of Medicine, 7th edition 2006, defines INR as a rating of a patient's PT ratio, used as a standard for monitoring the effects of [MEDICATION NAME]. A nursing note for Resident #35 by LVN D dated 5/7/12 at 11:00 a.m. indicated PT/INR panic values were phoned by the lab services, and Resident #35's physician was notified. No other notes that pertained to lab values were in the clinical record for that shift. During an interview on 5/15/12 at approximately 12:45 p.m., LVN D said she called the physician's office regarding the panic lab results for Resident #35 and did not know who she talked to, but she let them know she was faxing it. LVN D said she did not follow up with the lab results, but passed it in report to the next nurse. A nursing note for Resident #35 for the next shift (2-10) dated 5/7/12 and timed 9:00 p.m. had one entry by LVN E that made no mention of the panic laboratory values. Resident #35's May 2012 MAR indicated [REDACTED]. During an interview on 5/15/12 at 2:15 p.m., LVN E said she was told in report about the critical lab value for Resident #35, and the doctor was faxed. She said she did not try to call again and gave the next dose of [MEDICATION NAME] since there were no new orders. She further said the fax machine was broken during her shift and not fixed until the next day. A nursing note for Resident #35 for the next shift (10-6) dated 5/8/12 and untimed had one entry by LVN F that made no mention of the panic laboratory values. During an interview on 5/15/12 at 2:58 p.m., LVN F said the laboratory results for Resident #35 were faxed to the doctor and she did not look at the results or notify the physician because the shift before her had taken care of that. A nursing note dated 5/8/12 at 11:00 a.m. by LVN G indicated that Resident #35 complained of nausea. The FNP was in the facility to examine the resident and new orders were received. The note did not mention the panic PT/INR result. Physician telephone orders for Resident #35 dated 5/8/12 regarding the 11:00 a.m. nursing note and the resident's complaint of nausea read, "1) 3 view of abdomen: regarding abdominal pain, 3) SSE daily times 3 days, 3) CBC, CMP, UA, amylase and lipase." (www.labtestsonline.org accessed 5/22/12 indicated amylase and lipase are tests to determine pancreatitis, inflammation of the pancreas.) A nursing note for Resident #35 dated 5/8/12 at 1:45 p.m. by LVN G indicated there was still no response from MD office regarding panic PT/INR. LVN G called the office and received an order to hold the [MEDICATION NAME] for 2 days and then decrease the dose to 4 mg every day. That was 26 hours and 45 minutes since first receipt of the panic lab values. During an interview on 5/15/12 at 11:50 a.m., LVN G said she did not know about Resident #35's panic lab results until 5/8/12 at approximately 1:45 p.m. when she called the office to get new orders since the lab values had not been addressed. A physician's telephone order for Resident #35 dated 5/8/12 related to LVN G's phone conversation about panic lab values read, "1) hold [MEDICATION NAME] for 2 days, 2) decrease [MEDICATION NAME] to 4 mg by mouth every day, 3) PT/INR in one week." An abdominal x-ray report for Resident #35 dated 5/8/12 and faxed to the facility at 9:59 p.m. read, "Impression: "1) Distention of the colon between the right colon and mid descending colon. There is no sigmoid nor rectal air, therefore early colon obstruction versus ileus must be clarified. 2) Follow-up recommended." A nursing note for Resident #35 dated 5/9/12 at 4:30 a.m. had an entry that read the resident was hollering and complained of abdominal pain. At that same time, the abdominal x-ray results were faxed to the physician's office. A nursing note for Resident #35 dated 5/9/12 at 6:10 a.m. indicated the resident was yelling out with complaints of abdominal pain. The resident's abdomen was distended. The ADON and FNP were notified of the change in condition, elevated BP, and abdominal x-rays. Orders were received to send the Resident #35 to the local ER for evaluation and treatment. At 7:15 a.m., EMS arrived to transport Resident #35. A May 2012 anticoagulation monitoring sheet for Resident #35 indicated no symptoms abdominal pain or nausea present on 5/7/12, 5/8/12, or 5/9/12 for all nursing shifts. During an interview on 5/15/12 at 12:10 p.m., Resident #35's FNP said she was at the facility on 5/8/12 around 11:00 a.m. The FNP said her first knowledge of the panic PT/INR was on 5/8/12 around 2:00 p.m. when the facility called the office and the orders were given to hold the [MEDICATION NAME] for 2 days. The history and physical report, with a dictation date of 5/9/12, received from the admitting hospital for Resident #35 noted the resident was transferred from another local hospital on [DATE] where the chief complaint was abdominal pain. Resident #35 was intubated due to [MEDICAL CONDITION]. Resident #35's hemoglobin was 4.5 (normal range 13.5-18 g/dL in men) and INR was 4.9 (normal range 2-3 seconds) at the transferring hospital. During admission, further labs included a PT of 55.7 (normal range 9.45-13 seconds), INR of 5.0 (normal range 2-3 seconds), and hemoglobin of 4.5 (normal range 13.5-18 g/dL in men). The assessment and plan read Resident #35 was admitted with [MEDICAL CONDITION] and placed on a mechanical ventilator. The resident also had symptomatic [MEDICAL CONDITION] and received a transfusion of 4 packs of red blood cells. The report indicated the resident was taking [MEDICATION NAME], but the physician at the hospital was unsure why the resident was receiving it. The attending physician ordered to give fractioned plasma and vitamin K to reverse the INR. Resident #35's condition was listed as critical and he was admitted to the Intensive Care Unit. Mosby's Dictionary of Medicine, 7th edition 2006, defines hemoglobin as complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs. During the hospital admission on 5/10/12, Resident #35 had a esophagogastroduodenoscopy (a endoscopic test that permits direct visualization of the upper gastro-intestinal tract) with biopsy and colonoscopy. The post-operative [DIAGNOSES REDACTED]. During an interview on 5/15/12 at 3:20 p.m., the attending physician for Resident #35 said the resident was admitted with a [MEDICAL CONDITION] with [MEDICAL CONDITION] and giving the 5/7/12 [MEDICATION NAME] 5 mg dose after the panic labs were received only exacerbated his condition. During an interview on 5/15/12 at 3:00 p.m., LVN C said the physician should have been called regarding the panic level PT/INR for Resident #35 and if no response, the nurse should have called again. During an interview on 5/15/12 at 3:08 p.m., the DON said the physician should have been contacted regarding the PT/INR level and the medication held until new orders were received. During an interview on 5/15/12 at 3:55 p.m., the corporate nurse said she could see where the facility "dropped the ball" regarding Resident #35. A policy and procedure dated April 2007 and titled lab and diagnostic test results clinical protocol read, "Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: ...3. The resident's clinical status is unclear or worsening. 4. High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician..." The policy also indicated direct voice communication is the preferred way of informing the physician of any lab results requiring immediate notification. The policy also read if the physician does not respond to the immediate notification within an hour, the nursing staff should contact the medical director for assistance. A policy and procedure dated April 2007 and titled adverse consequences and medication related problems read, "The facility evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include an adverse drug reaction and side effects." An undated policy and procedure titled abuse prohibition read "The facility will not condone resident abuse, neglect or mistreatment or misappropriation of resident property by anyone, including staff members, other residents etc..." The administrator and DON were notified on 5/15/12 at 3:55 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 5/15/12 at approximately 5:20 p.m. and included: "1) All residents receiving [MEDICATION NAME] and additional anti-coagulations charts and labs have been reviewed to ensure PT/INR parameters are within acceptable limits. 2) All licensed nursing staff will be in-serviced regarding policy and procedure for panic lab values beginning on 5/15/12 and will be ongoing. 3) In addition to immediate notification to the physician, all panic lab values will be reported to the DON and administrator upon receipt. 4) In the event that the attending physician does not respond within two hours the medical director will be contacted. 5) Anticoagulation therapy monitoring log is currently in the MAR for each Resident receiving anticoagulation medication and assessed every shift." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: An in-service was performed with nursing staff to include: Critical lab monitoring, notification of physician, DON and administrator, information on lab resolution form, location of lab resolution form (steps to take when critical lab value identified), and what the nurse's documentation must include. Documentation of all residents who were on anticoagulation therapy charts reviewed for monitoring and lab values. Documentation received of anticoagulation sheets in place regarding the 10 residents currently taking [MEDICATION NAME]. Five nurses were interviewed regarding the recognition of panic lab values and the notification to the physician. Five of 5 nurses were able to identify the process in place and the new critical lab resolution form with the steps to take in notification and resolution. On 5/16/12 at 2:40 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 5/15/12 at 3:10 p.m., the DON said 10 residents were taking [MEDICATION NAME].