Every finding on record at Pine View Health and Rehabilitation Center

Based on staff interview, record review, and facility policy review, the facility failed to ensure Payroll-Based Journal (PBJ) staffing information was accurate and corrected prior to submission to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed in 2025. FY (Fiscal Year) Quarter 3 2025 (April 1 - June 30) Findings include:A review of the facility's policy, Payroll Based Journal dated 6/1/2025, revealed, .It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. A record review of the PBJ Data Report, for FY (Fiscal Year) Quarter 3 2025 (April 1 - June 30) revealed the facility triggered for excessively low weekend staffing, no Registered Nurse (RN) coverage for four (4) or more days, and failure to provide licensed nursing coverage 24 hours per day. The facility also triggered a one-star staffing rating.On 1/13/26 at 9:00 AM, during an interview, the Director of Nursing (DON) stated she was aware the PBJ data reflected the facility triggered for a one-star staffing rating, excessively low weekend staffing, no RN coverage during a 24-hour period, and failure to maintain licensed nursing coverage 24 hours per day. The DON stated that RNs were present in the building daily for eight (8) hours and licensed nurses were present daily. She further stated the corporate office failed to submit the PBJ data correctly.On 1/13/26 at 10:00 AM, during an interview, the Administrator confirmed he was aware the PBJ report indicated the facility triggered for a one-star staffing rating, excessively low weekend staffing, no RN coverage during a 24-hour period, and failure to maintain licensed nursing coverage 24 hours per day. The Administrator stated he questioned the report with the corporate office and was informed the PBJ data had been submitted incorrectly to CMS.On 1/13/26 at 10:30 AM, during an interview the Consultant confirmed the facility triggered for a one-star staffing rating, excessively low weekend staffing, no RN coverage during a 24-hour period, and failure to maintain licensed nursing coverage 24 hours per day. The Consultant stated PBJ data for several facilities within the corporation had been submitted incorrectly by the corporate office and that the company was in the process of correcting the issue.

Based on observation, interview, and record review, the facility failed to follow a physician's order related to ensuring that catheter tubing was anchored to prevent trauma for one (1) of (19) sampled residents. Resident #85.Findings include:On 1/14/26 at 8:36 AM, during an observation and interview, Resident #85 was lying in bed preparing for wound care and was noted to have an indwelling catheter with no leg anchor or strap securing the tubing. Resident #85 stated she would wear a leg anchor for the tubing if the staff provided one. On 1/14/26 at 8:55 AM, during an interview, Registered Nurse (RN) #1 confirmed that Resident #85 did not have a leg anchor in place and reported she was unsure if there was a physician's order related to the leg anchor.On 1/14/26 at 9:29 AM, during an interview, Licensed Practical Nurse (LPN) #1 reported it was the nurse's responsibility to ensure leg anchors were in place and stated Resident #85 often refused even though she had explained to the resident that leg anchors were used to prevent trauma.On 1/14/26 at 10:30 AM, during an interview, the Director of Nursing (DON) reported it was her expectation for nurses to follow physician orders and if a resident refused, the nurse should complete documentation indicating the refusal.A record review of the admission Record revealed the facility admitted Resident #85 on 1/4/24 with current diagnoses including Paraplegia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/25 revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated she was cognitively intact.A record review of the Order Details revealed Resident #85 had a Physician's Order dated 8/1/24 for LEG STRAP to anchor indwelling catheter in place q (every) shift.A record review of the Task: Ensure foley (indwelling) cath (catheter) leg strap is in place with a Look Back of 14 days for Resident #85 was documented as yes indicating the strap was in place.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure comprehensive care plan interventions were implemented related to anchoring indwelling catheter tubing for one (1) of 19 sampled residents. Resident #85. Findings include:A review of the facility's policy, Comprehensive Care Plans, dated 6/4/25, revealed, .It is the policy of this facility to.implement a comprehensive person-centered care plan for each residents.that includes measurable objectives and timeframes to meet a resident's medical, nursing.needs and.meet professional standards of quality.Policy Explanation and Compliance Guidelines.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident #85A record review of the Care Plan Detail revealed Resident #85 had a Focus of .Indwelling Catheter. with Interventions/Tasks of Foley (Indwelling) catheter: check leg anchor q shift.A record review of the Order Details revealed Resident #85 had a Physician's Order dated 8/1/24 for LEG STRAP to anchor indwelling catheter in place q (every) shift.During an observation and interview on 1/14/26 at 8:36 AM, Resident #85 was lying in bed preparing for wound care and did not have a leg anchor or strap securing catheter tubing. During an interview on 1/14/26 at 8:55 AM, Registered Nurse (RN) #1 confirmed that Resident #85 did not have a leg anchor in place. After reviewing the care plan, she confirmed there was a care plan intervention for the resident to have a leg strap or anchor for the catheter tubing.During an interview on 1/14/26 at 10:15 AM, RN #2/Care Plan Nurse confirmed the catheter care plan for Resident #85 included an intervention of a leg anchor for the catheter tubing. She stated that staff lets her know if a resident frequently refuses interventions and the care plan be revised. She reported that the care plan should reflect the actual care, and she expected staff to implement care plan interventions.During an interview on 1/14/26 at 10:30 AM, the Director of Nursing (DON) reported it was her expectation for nurses to implement comprehensive care plan interventions and that if a resident refused, the nurse should complete documentation indicating the refusal.A record review of the admission Record revealed the facility admitted Resident #85 on 1/4/24 with current diagnoses including Paraplegia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/25 revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated she was cognitively intact.

Based on observation, interview, facility policy review and record review, the facility failed to revise the resident's care plan to ensure all appropriate disciplines were assigned to interventions for one (1) of (19) sampled residents. Resident #61. Findings include:A review of the facility's policy, Care Plan Revisions Upon Status Change, dated 11/14/25, revealed, .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed and revised as necessary. 2. Procedure for reviewing and revising the care plan. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report. new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care.A record review of the Care Plan Report revealed Resident #61 had a Focus of .(Indwelling Suprapubic) Catheter. with Interventions/Tasks of Subrapubic catheter care every shift. and the Position assigned as RN (Registered Nurse)/LP (Licensed Practical) . only.On 1/12/26 at 3:20 PM, during an observation and interview, Certified Nurse Aide (CNA) #1 was observed providing suprapubic catheter care to Resident #6. She reported this was the first resident for whom she had performed suprapubic catheter care. She confirmed she documented completion in the resident's task section on the computer.On 1/14/26 at 10:20 AM, during an interview, Registered Nurse (RN) #1 reported she provided suprapubic catheter care to two (2) residents in the facility, including Resident #61. She reported that she documented completion on the TAR. She was not aware CNAs were also performing the catheter care and documenting completion in the CNA task section.On 1/14/26 at 10:35 AM, during an interview, RN #2 confirmed Resident #61's care plan listed suprapubic catheter care as an intervention assigned to nursing staff only and did not include CNAs. She further confirmed CNA task documentation listed suprapubic catheter care for CNAs to complete and stated the care plan should include all positions assigned to the intervention. She stated that CNAs were omitted in error and the care plan needed to be revised to include the CNA discipline for providing suprapubic catheter care. On 1/14/26 at 11:32 AM, during an interview, the Director of Nursing (DON) reported she was made aware the care plan for Resident #61 did not include CNAs for suprapubic catheter care and stated her expectation was for care plans to include all disciplines responsible for the resident's care.A record review of the admission Record revealed the facility admitted Resident #61 on 11/11/25 with diagnoses including Malignant Neoplasm of Prostate.A record review of the Order Summary Report revealed active orders for Resident #61 included suprapubic catheter care every shift.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/25, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact, and Section H indicated the resident had an indwelling catheter, including a suprapubic catheter.A record review of the Treatment Administration Record (TAR) revealed suprapubic catheter care for Resident #61 was documented as completed every shift and signed off by nursing staff.A record review of the Task: Suprapubic Cath Care dated 1/1/26 through 1/14/26 for Certified Nurse Aides (CNAs) revealed Resident #61 had CNA task documentation marked yes for completion each shift.

Based on observation, interview, and record review, the facility failed to ensure residents' rights to a safe, clean, and homelike environment by not ensuring privacy curtains were clean and laundered for two (2) of (19) sampled residents. Residents #9 and #20.Findings include:A review of the facility's policy, Resident Rights, (undated) revealed, Resident rights. The resident has the right to a dignified existence.8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment.A record review of the facility's document, Environmental Services Cleaning Procedure for Common Items (undated) revealed for Walls, Blinds and Curtains the Cleaning Procedure was When visibly dusty or soiled.On 1/12/26 at 11:11 AM, during an observation and interview, Resident #9 reported she requested her privacy curtain be washed due to reddish-brown stains in multiple areas but that it had not been removed or laundered following her request.On 1/13/26 at 2:46 PM, during the Resident Council meeting, residents reported privacy curtains in resident rooms, including Residents #9 and #20, had not been laundered or changed. On 1/14/26 at 9:04 AM, during an interview and observation, Resident #20 reported she asked to have her privacy curtain cleaned but was informed the stains were from her roommate's tube feeding solution spilling onto the curtain. She reported she had never seen her privacy curtain cleaned since admission, and the privacy curtain was observed to have several large brown stains near the bed.On 1/14/26 at 12:36 PM, during an interview and observation, the Housekeeping Supervisor #1 reported privacy curtains were removed and cleaned upon request, with maintenance responsible for removal and rehanging and housekeeping responsible for washing and drying. During the observation of Resident #20's privacy, the Housekeeping Supervisor verified it was visibly soiled and stated it would be removed, washed, and rehung. She reported her expectation was for staff to ensure residents' needs were met and promptly reported.On 1/14/26 at 12:45 PM, during an interview, the Administrator reported his expectation was for housekeeping and environmental services staff to ensure privacy curtains for residents were changed and cleaned. Resident #9A record review of the admission Record revealed the facility admitted Resident #9 on 1/4/23 with current diagnoses including Type Two (2) Diabetes Mellitus.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/25 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.Resident #20A record review of the admission Record revealed the facility admitted Resident #20 on 7/21/23 with current diagnoses including Chronic Obstructive Pulmonary Disease.A record review of the MDS with an ARD of 12/30/25 revealed Resident #20 had a BIMS score of (15), which indicated the resident was cognitively intact.

Based on observation, interview, facility policy review and record review, the facility failed to provide enteral feeding care in accordance with professional standards of practice by not documenting the date and time the feeding was hung, which was necessary to alert staff when the bag must be changed to prevent complications such as contamination and infection for one (1) of (12) residents observed with enteral feedings, Resident #5.Findings include:A review of the facility's policy, Care and Treatment of Feeding Tubes, with a reviewed/revised date of 10/22/25, revealed, Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.On 1/11/26 at 11:45 AM, during an observation, Resident #5 was lying in bed. There was an enteral feeding hanging from a pole. There was no date or label on the bag indicating the date and time it was hung.On 1/11/26 at 11:46 AM, during an interview and observation, Laundry #2 worker who was immediately present in the hallway outside the resident's room observed and agreed that she did not see a date or time documented on the bag.On 1/14/26 at 11:05 AM, during an interview, Licensed Practical Nurse (LPN) #1 reported it was the responsibility of the nurse who changed Resident #5's tube feeding bag to label and date the bag and explained the purpose of labeling was to ensure the bag was not outdated and to prevent infection or bacterial growth if the feeding solution remained in the bag too long.On 1/14/26 at 11:10 AM, during an interview, the Director of Nursing (DON) reported the purpose of labeling and dating enteral feedings was to ensure the feeding was used within twenty-four (24) hours to prevent expiration and contamination. A record review of the Order Summary Report revealed Resident #5 had a Physician's Order, dated 8/8/24, for Enteral Feed Order TWO CAL: 40/ml/hr (milliliters/hour) .A record review of the admission Record revealed the facility admitted Resident #5 on 9/19/23 with diagnoses including Dysphagia Following Cerebral Infarction.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired.

Based on staff interview, record review and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) regarding anticoagulant medication for one (1) of 18 residents reviewed. Resident #10 Findings include: A record review of the facility's policy MDS with a revision date of 09/25/2017 revealed Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments .Procedure .Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy . Record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 05/15/24 indicated Resident #10 received anticoagulant medication for seven (7) days during the look back period. Record review of Resident #10's .Order Review Batch Update revealed she had Physician's Orders for Aspirin 81 milligram (mg) (non-steroid anti-inflammatory medication) and Plavix Tablet 75 mg (anti-platelet medication). There were no orders for anticoagulant medications. On 06/19/24 at 2:00 PM, during an interview with the MDS Nurse/Licensed Practical Nurse (LPN) #1, she confirmed the MDS with an ARD of 05/15/24 for Residents #10 was inaccurately coded because she did not receive anticoagulant medications. On 6/19/24 at 2:15 PM, during an interview with the MDS Coordinator/Registered Nurse #1, she explained the facility completes a scrub report prior to submitting the MDS. She confirmed Resident #10's MDS was coded in error and missed on the review. On 6/19/24 at 3:20 PM, during an interview with the Director of Nursing (DON), she confirmed the MDS was coded inaccurately for Resident #10, and she expected all MDS assessments to be coded accurately. Record review of the Admission Record revealed the facility admitted Resident #10 on 11/02/2006 with diagnoses including Hemiplegia and Hemiparesis.

Based on observation, staff interview, and record review, the facility failed to ensure a resident's right to a dignified experience, as evidenced by not providing a privacy covering for a urinary drainage bag for one (1) of nine (9) residents with an indwelling catheter. (Resident #17) Findings include: On 6/16/24 11:35 AM, during an observation, Resident #17 was lying in bed and a urinary catheter drainage bag was hanging from the right side of the lower bed. The urinary drainage bag was not covered and the urine in the bag was visible from the hallway. On 6/17/24 at 9:15 AM, in an interview and observation with Registered Nurse (RN) #2, she confirmed Resident #17 had an indwelling catheter and the drainage bag was not covered, making the urine visible. RN #2 explained the visible urine was a dignity issue for the resident. On 6/18/24 at 9:15 AM, in an interview with the Director of Nursing (DON), she revealed urinary drainage bags should have a privacy covering because it was a dignity issue for the resident. Record review of the Admission Record revealed the facility admitted Resident #17 on 10/19/23 with current Paraplegia and Neuromuscular Dysfunction of Bladder. Record review of the Order Listing Report revealed Resident #17 had a Physician's Order, dated 5/10/24, for a Foley (Indwelling) catheter.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the chemical sanitizer for a low-temperature dishwasher had a concentration of at least 50 parts per million (ppm) for (1) of two (2) dishwasher observations. Findings include: A review of the facility's policy, Isolation/Infection Control - Non-Disposal Service Ware, Effective Date 11/30/2014, revealed, Policy: Isolation and Infection Control guidelines issued by the Center for Disease Control are followed .Procedure .Low temperature dish machines .use a chemical sanitizer .The required chemical sanitizer concentration is 50 ppm for a chlorine based sanitizer . On 6/17/24 at 10:07 AM, during an interview and observation with the Dietary Manager (DM), the low-temp dishwasher Hypochlorite (chlorine) on the dish surface final rinse was below 10 ppm. The DM confirmed the chlorine ppm was registering below 10. The DM explained adequate chlorine levels were important to help with infection control and stated she would call the Maintenance Director regarding the sanitation concentration. On 6/17/24 at 10:36 AM, an interview with the Maintenance Director revealed the low-temperature dishwasher chlorine was registering below 10 ppm. He advised he would contact the manufacturer to provide further maintenance and a representative would come to the facility. On 6/20/24 at 11:40 AM, an interview with the Administrator, he stated he was aware the low temperature dishwasher chlorine level was below 10 ppm when SA observed the DM test the sanitation on 6/17/24. The Administrator stated he planned to personally in-service the staff on requirements for dishwasher sanitation.

Based on observation, staff interview, and record review, the facility failed to maintain proper placement of urinary drainage tubing to prevent the possible spread of infection for one (1) of nine (9) residents with an indwelling catheter. (Resident #17) Findings include: Review of the facility's policy, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, revised 9/2017, revealed, . The purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs) .Steps in Procedure .6 .Do not place the drainage bag on the floor . Record review of the Order Listing Report revealed Resident #17 had a Physician's Order, dated 5/10/24, for a Foley (Indwelling) catheter. On 6/16/24 at 11:35 AM, during an observation, Resident #17 was lying in bed and a urinary catheter drainage bag was hanging from the right side of the lower bed and the drainage tubing on the floor. On 6/17/24 at 9:15 AM, in an interview and observation with Registered Nurse (RN) #2, she confirmed Resident #17 had an indwelling catheter and the drainage tubing was on the floor of the resident's room. RN #2 stated the tubing on the floor was an issue with infection control. On 6/18/24 at 9:15 AM, in an interview with the Director of Nursing (DON), she revealed catheters could be a cause of infection and the tubing should not touch the floor. She stated it was the responsibility of all nursing staff to ensure catheter drainage tubing was not touching the floor. Record review of the Admission Record revealed the facility admitted Resident #17 on 10/19/23 with current diagnoses that included Paraplegia and Neuromuscular Dysfunction of Bladder.

Based on staff interview, record review, and facility policy review, the facility failed to implement a Nurse Practitioner's (NP) recommendation for a specialty mattress for a resident with a pressure ulcer (PU) for one (1) of three (3) residents reviewed with PUs. Resident #32 Findings include: A review of the facility's policy Skin and Wound with revision date of 01/24/2022 revealed Policy: To provide a system for .implementing resident centered interventions to promote skin health, prevention, and healing of pressure injuries . A record review of a timeline provided by the facility of Resident #32's PUs revealed Resident #32 acquired a deep tissue injury (DTI) (a type of pressure injury) to the right and left heel and a left lateral heel DTI on 03/11/24. On 04/02/24, Resident #32 acquired a sacrum wound that was a Stage II PU. She received a specialty (air) mattress on 05/22/24. Record review of Resident #32's Progress Note Details of the wound care NP revealed 4/30/24 . Will order patient air mattress . 5/14/24 .patient has not received air mattress .5/21/24 .The patient has not received the air bed . A record review of the 5-Day (Reentry from an acute hospital) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/24 revealed Resident #32 was severely cognitively impaired and had three (3) unstageable pressure wounds and indicated there were no pressure devices for her bed or chair coded in Section M for skin conditions. A record review of the Customer Portal maintenance list revealed Resident #32 received an APM2 (type of specialty air mattress) and pump on 5/22/24. On 06/19/24 at 4:30 PM, during an interview with the Director of Nursing (DON), she stated she did not understand or know why Resident #32 did not receive an air mattress after the nurse practitioner ordered it on 4/30/24. She explained she expected the staff to follow the NP's recommendations and to place orders as soon as possible. On 06/19/24 at 5:00 PM, during an interview with Licensed Practical Nurse (LPN) #2/Wound Care nurse she confirmed the NP indicated in her progress notes on two (2) different dates that Resident #32 did not have an air mattress in place. She explained she remembered the NP asking about the air mattress, but it was forgotten about or maybe it was on order from maintenance. On 06/20/24 at 11:45 AM, during an interview with the Maintenance Director, he explained the facility always had low air loss mattresses in-house. The facility placed orders for new mattresses in November 2023. He explained currently there were four (4) low air loss mattresses that are available for use. He stated he always tries to keep one or two low air loss mattresses available but if the facility did not have any mattresses in house, he could order them and have them available the next day. On 06/20/24 at 2:00 PM, during an interview with the Wound Care NP, she explained when Resident #32 first got the PUs, she mentioned to LPN #2/Wound care nurse a verbal order to get the resident a low air loss mattress and after seeing resident a few more times she mentioned the air loss mattress again. She confirmed that she did not follow up on the reason why Resident #32 did not have a specialty mattress. Record review of the Admission Record revealed the facility admitted Resident #32 on 01/03/24 with current diagnoses including of Unspecified Dementia.

Based on Interview and Record Review, the facility failed to ensure resident grievances regarding food were resolved in a timely manner for nine (9) of 9 residents who regularly attended resident council meetings (Resident #8, Resident#12, Resident #13, Resident #14, Resident #15, Resident #19, Resident #20, Resident #53, and Resident #62) and a grievance regarding missing money for one (1) sampled resident. Resident #8. Findings Include: A record review of the facility's policy Complaint/Grievance with a revised date of 08/09/2018 revealed . Purpose: To support each resident's right to voice grievances; resulting in a follow-up and resolution while keeping the resident apprised of its progress toward resolution . The Grievance Office/designee shall act on the grievance an begin follow-up of the concerns or submit it to the appropriate department director for follow-up . On 12/13/22 at 10:55 AM, the SSA conducted a resident council meeting with nine (9) residents in attendance including the Resident Council President. During the meeting, the residents complained about food not being palatable, either not seasoned or overly salty, and sometimes not thoroughly cooked. Residents stated complaints had been made at resident council meetings and the concerns were discussed but never addressed except for asking what the residents would like for meals. All residents attending the resident council meeting stated the facility never let them know of anything being done to address their grievances regarding food. On 12/15/22 at 2:00 PM during an interview with the Administrator, she confirmed the residents had been complaining about the food and grievances were supposed to be by Social Services. The administrator stated if the residents continue to complain about the food, the grievance is not resolved, and she had not reviewed the grievance logs. The Administrator stated staff needed additional training and in-services on dealing with grievances and resolving them. On 12/15/22 at 2:20 PM, during an interview with the Dietary Manager, she confirmed residents had complained about food, but she has not attended any resident council meeting. She confirmed that residents do still complain about food. An interview on 12/15/22 at 3:15 PM with the SSD revealed the SSD did attend some resident council meetings and was the Grievance Contact person for the facility. The SSD stated grievances were discussed and she was responsible for ensuring grievances were addressed and ultimately resolved with some assistance at times from the Director of Nursing (DON). The SSD confirmed residents complain about food during resident council meetings. She agreed if the residents continued to complain about the food, the grievances were not resolved. On 12/15/22 at 3:30 PM, during an interview with Activity Director, she confirmed the residents complained about food in resident council meetings. She stated she did not always write the complaints on the minutes of the council meeting regarding food because the residents continue to bring it up and there was no need to continue writing what had already been discussed. She agreed the complaints regarding food had not been resolved. Resident #8 An interview on 12/12/22 at 09:42 AM with Resident #8 revealed she was admitted to the hospital in July 2022 and had a stay of over 2 weeks. Resident #8 stated when she came back from the hospital she noticed that items had been moved around in her room. Resident #8 stated prior to her hospitalization she had $160.00 in a small cardboard box that was sealed up with tape under her Sunday school book and her Bible was on top of the box. Upon return from the hospital her Bible had been moved and the money was missing. Resident #8 stated she informed the Social Service Director (SSD) that her money was missing. A review of the facility's grievance log revealed Resident #8's missing money was listed on the grievance log on July 18, 2022. A review of the grievance investigation report regarding Resident #8's missing money revealed the SSD looked for the money in the resident room and could not find it. There was no indication the money was replaced by the facility. An interview on 12/14/22 at 3:53 PM with the SSD confirmed when Resident #8 returned from her hospital stay, the resident told the SSD her money was missing that had been under her Bible in an envelope. The SSD stated she looked for the money but could not find it. The SSD stated she spoke with the resident's niece (Niece #1) regarding the lost money and the resident's niece told her the resident probably misplaced it, and not to worry about replacing it. In an interview on 12/14/22 at 4:34 PM with Niece #1 she denied anyone at the facility had contacted her regarding any missing money. Niece #1 stated she gives resident money when she visits with the resident and had given money to the resident in July. Niece #1 stated she knew it was over $100.00 but she wasn't sure exactly how much. An interview on 12/14/22 at 4:42 PM with Resident #8's niece (Niece #2) revealed Resident #8 told her about money missing from her room after she returned from a hospitalization . Niece #2 confirmed Niece #1 gives the resident money when she visits. Niece #2 stated no one from the facility had spoken to her about the resident missing any money. Review of Resident #8's Admission Record revealed the resident was admitted by the facility on 9/27/20 with medical diagnoses including Essential Primary Hypertension and Recurrent Depressive Disorder. Review of Resident #8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/22, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively Intact. 43283

Based on interview, record review, and facility policy review the facility failed to ensure a resident had access to personal funds on the weekend for one (1) of 19 sampled residents with potential to affect 64 residents with resident trust fund accounts of 87 total residents in the facility. Resident #8. Resident#8 Review of the facility's policy, Resident Trust Fund-Overview, with a revision date of 4/22/2019, revealed the care center will maintain all residents trust fund accounts in compliance with Federal and State regulations and with generally accepted accounting practices. An interview on 12/12/22 at 10:03 AM with Resident #8 revealed the resident had a trust fund account but was unable get money on the weekends because the office was closed on weekends. An interview on12/14/22 at 10:30 AM with the Social Service Director (SSD) revealed she previously issued the money in the business office, but Receptionist Central Supply (RCS) now keeps up with the money. The SSD stated when she was responsible for the money, residents had access to it on the weekends. An interview on 12/14/22 at 10:34 AM with RCS stated residents have access to their funds any time of the day and can get their funds anytime she is at work. She revealed that she works Monday through Friday 8AM to 5PM. RCS stated she is the only one that deals with the money and that if the residents need money on the weekend she tries to get them taken care of before the weekend. She confirmed that there is no other person here that gives out money on the weekends. On 12/14/22 at 03:40 PM in an interview with Administrator stated normally resident funds are available Monday thru Friday. She stated the residents are not able to get their money on Saturday and Sunday as the office staff is not present on Saturday and Sunday. She stated she was not aware of regulations concerning resident funds being available seven days a week. A review of Resident #8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/22, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on staff interview, record review. and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (2) of 19 residents reviewed. Resident #9 and Resident #11. Findings include: A record review of the facility's policy MDS with a revision date 09/25/2107 revealed The center conducts initial and periodic standardized, comprehensive and reproducible assessment no less than every three months for each resident including, but not limited to, the collection of date requiring functional status, strengths, weaknesses, and preferences using the federal and/or state required RAI (Resident Assessment Instrument). Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy . Resident #9 Record review of Resident #9's Admission Record revealed the facility admitted resident on 11/02/2006 with the diagnoses including Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting right dominant side. Record review of Resident #9's Quarterly MDS with an Assessment Reference Date (ARD) of 11/23/2022 revealed in section N-N0410 Medications received revealed resident received seven (7) days of anticoagulant medication in the seven (7) day look back period. Record review of Resident #9's Order Summary Report orders for active orders as of 10/25/2022 revealed the resident was prescribed Aspirin Tablet Chewable give 81 milligram (mg) via Peg-tube one time a day for circulation. There were no anticoagulant medications ordered. Record review of Resident #11's Admission Record revealed the facility admitted resident on 04/13/2016. The resident had current diagnoses including Angina Pectoris Unspecified and Pain in Left Arm. Record review of Resident #11's Order Summary Report active orders as of 11/28/22 revealed an order for Aspirin EC Tablet Delayed Release 81 mg give one tablet by mouth one time a day. There were no anticoagulant medications ordered. Record review of Resident #11's Quarterly MDS with an ARD of 12/05/2022 section N N0410 Medications received revealed resident received seven (7) days of anticoagulant medication in the seven (7) day look back period. On 12/15/22 at 2:00 PM, during an interview with MDS nurse/Licensed Practical Nurse (LPN) #1, she confirmed the MDS for both Resident # 9 and Resident #11 were coded for anticoagulant given. LPN #1 stated she thought Aspirin was classified as an anticoagulant. She stated she continues to learn by going through the RAI manual to complete the MDS assessment and confirmed the MDS's were coded inaccurately for anticoagulant use. On 12/15/22 at 2:20 PM, during an interview with the Director of Nursing (DON), she confirmed Aspirin was not an anticoagulant. She expects the MDS nurse to code the assessment accurately. She confirmed both MDS for Resident #9 and Resident #11 were coded inaccurately.

Based on observations, interviews, and record review, the facility failed to ensure staffing was posted and visible to staff, residents, and visitors for four (4) of four (4) days with potential to affect 87 of 87 residents in the facility. Findings include: A record review of the facility's policy Daily Nursing Staff Form with a revision date of 09/2017 revealed . Post beginning of each shift in a prominent place that is readily accessible to residents and visitors. Daily posting of this information is required for nursing homes participation in Medicate and Medicaid. Definition of Directly responsible for resident care includes but is not limited to activities such as assisting with ADL's (Activities of Daily Living), giving medications, supervising the care given STNA/CNA's (student nurse assistance/certified nurse assistant), performing nursing assessments, or notifying a physician about a change in condition . Facility observations on 12/12/22 and 12/13/22 revealed there was no posted facility staffing observed. An observation on 12/14/22 at 3:00 PM revealed a clear bin across from the Director of Nursing's (DON) office in front of the woman's bathroom with papers folded over. When papers were lifted, the bin had signage reading, Daily Staff Posting and Survey Results. The State Agency (SA) observed a staffing sheet for 12/13/22 with only 6A-6P filled in. On 12/15/22 at 09:00 AM, SSA observed clear bin with papers still bent over and the signage not visible. There were no staffing sheets. On 12/15/22 at 11:10 AM, during an interview with Licensed Practical Nurse (LPN) #2, she stated she previously was responsible for posting the daily staffing, but since she was now working in assessments, she did not know who was responsible for posting staffing. An observation and interview on 12/15/22 at 11:30 AM with the DON and Administrator revealed staffing sheets were not visible due to papers being folded over and staffing was not posted where all staff, residents, or guests could view, and no staffing was posted today. The Administrator reported the survey results have always been there in the clear sheets but did confirm the results are not clearly visible to anyone to see or review. The DON reported sometimes LPN#2 posted the staffing and sometimes the DON.

Based on facility statement review, record review and staff interview, the facility failed to refer Resident #2 for a Level II Pre-Admission Screening and Resident Review (PASRR) when the resident's status changed from being a Short Term Care (STC) resident to a Long Term Care (LTC) resident. This concern was identified for one (1) of 30 sampled residents reviewed. Findings include: Review of the untitled document on the facility's letterhead, dated 9/12/2019, provided and signed by the facility's Administrator, the facility does not have a Pre-Admission Screening and Resident Review (PASRR) policy. The facility follows State guidelines. The document was provided when asked for a policy on the PASRR process. Review of Resident #2's medical record document titled, PAS Summary and Physician Certification (Electronic PAS), dated 7/31/2017, revealed the section of the PASRR review for the Level II Referral Criteria was noted to be blank. The document revealed a mark to indicate that a Level II evaluation was not indicated at this time. The document was signed and dated, on 8/1/2017, by Resident #2's physician. Review of the facility's document titled, Progress Notes, dated 10/17/2017 at 11:10 AM, and electronically signed by the Social Services Staff (SSS), revealed Resident #2 decided to become a Long Term Care (LTC) resident at the facility. The note revealed Resident #2 no longer felt safe at home, and that Resident #2 wanted to stay at the facility, because his brother would no longer be living with him. The note revealed Resident #2 stated, I don't want to fall and no one help me either. Review of the facility's document titled, [DIAGNOSES REDACTED].#2's diagnoses, the onset dates for each diagnosis, and each diagnosis' rank. The document revealed the [MEDICAL CONDITION] Disorder [DIAGNOSES REDACTED].#2's primary [DIAGNOSES REDACTED].#4. The 12th [DIAGNOSES REDACTED]. During an interview, on 9/11/2019 at 11:18 AM, with the Director of Nursing (DON), it was determined that the current PASRR located on Resident #2's chart, did not reflect Resident #2's current status. The DON stated Resident #2 was first admitted , on 7/31/2017, as a short term resident for therapy services. The DON stated Resident #2 later changed his mind and wanted to stay. The DON confirmed a new PASRR should have been done when Resident #2 changed from a Short Term Care (STC) resident to a Long Term Care (LTC) resident. During an interview, on 9/11/2019 at 2:02 PM, with the facility's Admissions Coordinator (AC), it was confirmed that the current PASRR did not reflect the resident's current Long Term Care (LTC) status. The AC stated that at the time of admission, on 7/31/2017, Resident #2's intention was only to stay at the facility for short term skilled therapy care. The AC stated it was decided at a later date, that Resident #2 would remain in the facility as a Long Term Care resident. The AC stated that because of the resident's mental [DIAGNOSES REDACTED]. Review of the Face Sheet revealed Resident #2 was admitted by the facility, on 7/31/2017, with [DIAGNOSES REDACTED].

CI MS # Based on observation, interviews, record review and facility policy review, the facility failed to report to the State Agencies (SA), a fall with major injury that resulted in the death of a resident, related to lack of staff assistance, per resident assessment. This affected one (1) of seven (7) residents reviewed, Resident #4. Resident #4 had a [DIAGNOSES REDACTED]. Resident #1 fell on [DATE], and received a Head Injury and Skull Fracture, when Registered Nurse (RN) #1 toileted the resident without assistance and left him standing without assistance at the bedside. RN #1 was approximately 43 inches away from Resident #4, with the resident's bed between them, when Resident #4 became unbalanced and fell , hitting his head on the floor. Resident #4 subsequently died on [DATE], as a result of the fall. Resident #4 was assessed for transfer and mobility assistance due to balance issues. The facility did not report the fall with injury and subsequent death to the SA as required. The facility's failure to report Resident #4's fall with major head injury and death to the SA, placed this and other residents assessed for fall risk that required assistance, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), that began on [DATE], when staff failed to provide assistance as needed to prevent Resident #4's accident/fall, with major head injury and subsequent death; and also failed to report the incident as required. On [DATE] at 12:30 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ removed on [DATE]. The SA validated the A[NAME], and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.12 (c)-Reporting, F609, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, dated (MONTH) (YEAR), noted the facility Administrator would report to the State Survey Agency in accordance with State law. This policy noted if the events that cause the allegation involve abuse or result in serious bodily injury, the event must be reported immediately, but not later than two (2) hours after the allegation is made. A review of the facility's Exception Report, dated [DATE], revealed Resident #4 lost his balance on [DATE] at 1:50 PM, while standing. Documentation revealed Resident #4 had bleeding from his head and ears after the fall and complained of severe pain. The report was signed by RN #1 on [DATE]. Documentation included a statement by RN #1, noting she was assisting Resident #4 back to bed when Resident #4 asked her to straighten his bed and when she went around the bed, Resident #4 lost his balance and fell . Review of an ambulance report, dated [DATE], revealed Resident #4 was found in the floor, alert and oriented x 4 (person, place, time, situation). Patient had a blood pool behind his head and bleeding from the left ear. Patient stated the staff stood him up and dropped him. The report documented the resident had a laceration/hematoma to the back of the skull and bleeding from the ear. The resident was placed on a stretcher and taken to the hospital. Review of Resident #4's Computerized Tomography (CT) scan, dated [DATE], revealed, The study is significant for evidence of a hairline fracture left temporal bone extending into the external auditory canal with fluid possibly blood left external cord canal. Exam also shows what appears to be a very minimal amount of subarachnoid air in the posterior fossa on the left adjacent to the temporal bone. Review of the Discharge Summary, from the accepting hospital, with a discharge date of [DATE], revealed Resident #4 died as a result of a Basilar Skull Fracture, fall at the Nursing Home, and a Cerebral Contusion. Review of Resident #4's Certificate of Death, dated [DATE] at 4:54 AM, revealed the cause of death was Multi-organ Failure, due to Basilar Skull Fracture, as a consequence of a fall to the Floor Interview with Resident #4's Responsible Party (RP) on [DATE] at 8:31 AM, revealed Resident #4 died as a result of a fall at the facility when a nurse was helping him by herself. She stated she returned to the facility on [DATE], the day Resident #4 died , and notified the facility that he had expired. In an interview on [DATE] at 10:17 AM, the facility Administrator at the time of Resident #4's fall on [DATE], stated the investigation revealed RN #1 did take Resident #4 to the bathroom alone and when they got back to the bed the resident asked the nurse to straighten his covers. The Administrator stated that Resident #4 was on the left side of the bed from the foot, and the nurse was on the right side of the bed from the foot. The Administrator stated when RN #1 looked up, Resident #4 was falling, she could not catch him, and he fell to the floor, hitting his head. When the Administrator was asked if this incident involving Resident #4's fall with subsequent death should have been reported to the SA, the Administrator responded there was no willful intent on the nurse's part and they knew what happened. The Administrator confirmed the incident was not reported to the SA. Interview with the Director of Nursing (DON) on [DATE] at 9:30 AM, confirmed the facility did not report the incident involving Resident #4 when he fell on [DATE], and died on [DATE]. The DON stated the facility did not think it had to be reported to the State Survey Agencies because it was a witnessed fall and the facility was aware of what happened. When asked if a major injury should be reported, the DON replied, Yes. The Facility provided an acceptable Allegation of Compliance (AoC), which included: On [DATE] at 12:30 PM, the State Agency informed the Administrator, who started in the Administrator role on [DATE], of an Immediate Jeopardy with substandard quality of care, due to the facility's lack of supervision and failure to report a major injury of Resident #4. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 was care-planned at risk for falls and required assistance with most aspects of care. Resident #4's care plan dated [DATE], included: limited assistance times one (1) staff member for walking in room/corridor, supervision times one (1) staff member for locomotion on unit, extensive assistance times one (1) staff member for dressing, extensive assistance times one (1) staff member for eating, extensive assistance times one (1) staff member for locomotion off unit, extensive assistance times one (1) staff member for personal hygiene, extensive assistance times two (2) staff members for bathing, extensive assistance times two (2) staff members for bed mobility, extensive assistance times two (2) staff members for toilet use, and extensive assistance times two (2) staff members for transfers. Registered Nurse (RN) #1 did not follow the plan of care of Resident #4 who was extensive assistance times two (2) for toileting and transfers. Resident #4 had a Brief Interview for Mental Status (BIMS) of 12 as of [DATE], and participated in his plan of care. Resident #4 had a fall due to RN #1 was unable to catch Resident #4, and Resident #4 sustained a head injury on [DATE] at 1:50 PM. Resident #4 was standing to the left side of his bed after being assisted from the bathroom by RN #1. Resident #4 requested that RN #1 straighten his covers on his bed to prepare for bed. RN #1 asked Resident #4 was he good to stand while she proceeded to walk to the opposite side of the bed. Resident #4 confirmed that he was stable with standing unassisted. RN #1 saw Resident #4 falling backwards and called out to him while reaching out towards him. RN #1 was not able to catch Resident #4 as he was falling. RN #1 immediately began to assess Resident #4 who was noted to be bleeding from back of head and ears. RN #1 kept Resident #4's C-spine stable as she alerted Housekeeper #1 and CNA #1 to alert additional nursing staff. LPN #1 called the ambulance at 1:50 PM and the ambulance arrived at the facility at 1:56 PM. LPN #1 notified the Responsible Party on [DATE] at 2:00 PM that Resident #4 had a fall with a head injury and was being transported to the local emergency room . The Unit Manager notified the Medical Director on [DATE] at 2:06 PM, that Resident #4 had a fall with a head injury and was being transported to the local emergency room . Resident #4 arrived to the local emergency roiagnom on [DATE] at 2:20 PM . Resident #4 was diagnosed with [REDACTED]. On [DATE] at 12:42 PM, the Responsible Party of Resident #4, notified the Assistant Director of Nursing (ADON) that Resident #4 expired on [DATE], while in the hospital. Resident #4's Death Certificate dated [DATE], states that Resident #4's cause of death was due to Multi-organ Failure, Basilar Skull Fracture, and fall to floor. Corrective Actions: 1. On [DATE] at 1:52 PM, the Risk Manager and ADON entered the room and initiated an investigation of Resident #4's fall. 2. On [DATE] at 3:00 PM, the Risk Manager completed an in-service with RN #1 regarding not following the care plan of extensive assistance times two (2) for toileting and transfers to prevent falls. 3. On [DATE] at 4:30 PM, the Risk Manager and Director of Nursing (DON) initiated a Quality Assurance Performance Improvement (QAPI) and Performance Improvement Project (PIP) to decrease falls with review of interventions to prevent accidents. Interventions included completing fall investigation after each fall, medication review after each fall, in-serviced all caregivers on reporting changes with Activity of Daily Living (ADL) support and following Kardex/Care plans, care plans to be reviewed and updated after each fall, and referrals will be made to therapy as needed. 4. On [DATE] at 1:45 PM, the Risk Manager held a scheduled annual in-service on preventing / reporting of abuse and neglect, completing exception reports, and resident rights. The following associates received this training: one (1) of one (1) Activity associates, three (3) of three (3) Maintenance associates, one (1) of one (1) Business Office Associates, 42 of 42 CNAs, 18 of 20 Licensed Practical Nurses (LPN), eight (8) of nine (9) RNs, 11 of 13 Dietary associates, and 12 of 12 Housekeeping/Laundry associates. 5. On [DATE] at 5:00 PM, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Risk Manager, Business Office Manager, Housekeeping Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinator, Restorative Coordinator, Unit Manager, Admission/Marketing Nurse, and Social Services Director to discuss the events after Resident #4's fall on [DATE], and the importance of reporting major injuries to state agencies within two (2) hours of occurrence. The QA Committee also reviewed policies on supervision and prevention of accidents, abuse/neglect, following care plan, and observing for change in condition. There were no changes made to current facility policies. 6. On the evening of [DATE], between 5:30 PM-9:00 PM, Nurse Managers including the Social Services Director, Unit Manager, Medicare Nurse, MDS Coordinator, Restorative Coordinator, Admissions/Marketing Nurse, and ADON audited 87 of 87 residents for needs of assistance with ADLs comparing a new fall risk screen to the individual resident's plan of care and Kardex. No discrepancies were noted and no changes were made to the care plan of the 87 residents audited. 7. On [DATE] at 5:30 PM through [DATE] at 11:45 AM, the Risk Manager and DON completed all in-services for all staff members on supervision and prevention of accidents, reporting requirements for major injuries, and following the care plan and updating plan of care upon a resident's change of condition. Nine (9) of nine (9) RNs, 20 of 20 LPNs, 42 of 42 CNAs, 13 of 13 Dietary associates, three (3) of three (3) Maintenance associates, 12 of 12 Housekeeping/Laundry associates, and seven (7) of seven (7) Therapy associates have been in-serviced. All new hires will receive this training during new hire orientation by the Risk Manager. 8. On [DATE] at 6:00 PM, the Pharmacy Consultant completed a pharmacy review of nine (9) residents who fell in (MONTH) 2019, with no concerns noted. 9. On [DATE] at 6:03 PM, the Risk Manager notified the State Licensing Agency of the completed investigation of Resident #4's fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 10. On [DATE] at 6:18 PM, the Risk Manager notified the Medicaid Fraud Control Unit (Attorney General) office that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 11. On [DATE] at 6:22 PM, the Risk Manager notified the local Police Department that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 12. On [DATE] at 12:10 PM, the Risk Manager audited all other Exception Reports since [DATE], for major injuries, with zero (0) of 142 Exception Reports resulting in major injuries. 13. The Administrator will report all results of the established monitoring to the Quality Assurance Committee meeting for the immediate corrective plan of action of any deficient practice. 14. No associate can work until they have received this in-service training. The facility alleges that all corrective actions were completed on [DATE], and Immediate Jeopardy removed as of [DATE]. Validation of the Allegation of Compliance included: The SA validated through record review and interview that Resident #4 was admitted on [DATE], with a [DIAGNOSES REDACTED]. The SA validated that Resident #4 fell on [DATE], after RN #1 assisted him to the toilet without assistance and left him standing, unassisted, as the foot of the bed while she went to the other side of the bed, out of arms reach of the resident. The SA validated Resident #4 was transferred to the hospital and diagnosed with [REDACTED]. The SA validated notification to the RP and the Medical Director. The SA validated the facility's Corrective Actions: 1. The SA validated through interviews and record review that on [DATE], the Risk Manager and ADON initiated an investigation of Resident #4's fall. 2. The SA validated through interviews and record review that on [DATE], the Risk Manager completed an in-service with RN #1 regarding not following the care plan of extensive assistance times two (2) for toileting and transfers to prevent falls. 3. The SA validated through interviews and record review that on [DATE], the Risk Manager and Director of Nursing (DON) initiated a Quality Assurance Performance Improvement (QAPI) and Performance Improvement Project (PIP) to decrease falls with review of interventions to prevent accidents. Interventions included completing fall investigation after each fall, medication review after each fall, in-serviced all caregivers on reporting changes with Activity of Daily Living (ADL) support and following Kardex/Care plans, care plans to be reviewed and updated after each fall, and referrals will be made to therapy as needed. 4. The SA validated through interviews and record review that on [DATE], the Risk Manager held a scheduled annual in-service on preventing/reporting of abuse and neglect, completing exception reports, and resident rights. The following associates received this training: one (1) of one (1) Activity associates, three (3) of three (3) Maintenance associates, one (1)of one (1) Business Office Associates, 42 of 42 CNAs, 18 of 20 Licensed Practical Nurses (LPN), eight (8) of nine (9) RNs, 11 of 13 Dietary associates, and 12 of 12 Housekeeping/Laundry associates. 5. The SA validated through interviews, sign-in sheets, and record review, that on [DATE], an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Risk Manager, Business Office Manager, Housekeeping Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinator, Restorative Coordinator, Unit Manager, Admission/Marketing Nurse, and Social Services Director to discuss the events after Resident #4's fall on [DATE], and the importance of reporting major injuries to state agencies within two (2) hours of occurrence. The QA Committee also reviewed policies on supervision and prevention of accidents, abuse/neglect, following care plan, and observing for change in condition. There were no changes made to current facility policies. 6. The SA validated through interviews and record review that on the evening of [DATE], Nurse Managers including the Social Services Director, Unit Manager, Medicare Nurse, MDS Coordinator, Restorative Coordinator, Admissions/Marketing Nurse, and ADON audited 87 of 87 residents for needs of assistance with ADLs, comparing a new fall risk screen to the individual resident's plan of care and Kardex. No discrepancies were noted and no changes were made to the care plan of the 87 residents audited. 7. The SA validated through interviews and record review on [DATE], through [DATE], the Risk Manager and DON completed all in-services for all staff members on supervision and prevention of accidents, reporting requirements for major injuries, and following care plan and updating plan of care upon a resident's change of condition. Nine (9) of (9) RNs, 20 of 20 LPNs, 42 of 42 CNAs, 13 of 13 Dietary associates, three (3) of (3) Maintenance associates, 12 of 12 Housekeeping/Laundry associates, and seven (7) of (7) Therapy associates have been in-serviced. The SA validated that all new hires will receive this training during new hire orientation by the Risk Manager. 8. The SA validated through interviews and record review that on [DATE], the Pharmacy Consultant completed a pharmacy review of nine (9) residents who fell in (MONTH) 2019, with no concerns noted. 9. The SA validated through interviews and record review on [DATE], the Risk Manager notified the State Licensing Agency of the completed investigation of Resident #4's fall on [DATE], which resulted in death on [DATE] due to Multi-organ Failure and Basilar Skull Fracture. 10. The SA validated through interviews and record review on [DATE], the Risk Manager notified the Medicaid Fraud Control Unit (Attorney General) office that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 11. The SA validated through interviews and record review on [DATE] at 6:22, the Risk Manager notified the local Police Department that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 12. The SA validated through interviews and record review on [DATE], the Risk Manager audited all other Exception Reports since [DATE], for major injuries with zero (0) of 142 Exception Reports resulting in major injuries. 13. The SA validated through interview the Administrator will report all results of the established monitoring to the Quality Assurance Committee meeting for the immediate corrective plan of action of any deficient practice. 14. The SA validated through interviews and record review that no associate worked until they had received this in-service training. The SA validated that all corrective actions were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].

CI MS # Based on observation, interviews, record review, and facility policy review, the facility failed to implement the plan of care to provide adequate assistance to prevent accidents and/or major injury, including death, for one (1) of seven (7) residents reviewed, Resident #4. Resident #4 was assessed and care planned for two (2) person assistance with transfer and mobility, related to balance. He fell on [DATE], when RN #1 took him to the bathroom unassisted, then left him at the bedside unassisted, while she went to the other side of the bed. The fall resulted in a Head Injury and Skull Fracture when Registered Nurse (RN) #1 was unable to reach the resident to break his fall on [DATE]. She was approximately 43 inches away from Resident #4, with the resident's bed between them, when Resident #4 fell . Resident #4 died on [DATE], as a result of the fall. The facility's failure to follow Resident #4's plan of care to provide supervision and assistance to prevent accidents, resulted in major injury/death to Resident #4, and placed other residents assessed for assistance needs, in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE], when RN #1 failed to provide the needed assistance, per care plan, to help prevent the accident/fall and major injury, resulting in Resident #4's death. On [DATE] at 12:30 PM, the State Agency notified the facility's Administrator of the IJ and Substandard Quality of Care (SCQ). The facility submitted an acceptable Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ removed on [DATE]. The SA validated the A[NAME] and determined the IJ was removed, prior to exit. Therefore the scope and severity for 42 CFR(s) 483.21 (b)(1)-Comprehensive Care Plans, F656, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Care Plan-Comprehensive, dated (MONTH) (YEAR), revealed the facility would develop and maintain a Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs of the resident. This policy noted the Care Plans are revised as changes in the resident's condition dictate and are reviewed at least quarterly. Review of the Care Plan (CP) dated [DATE], with a target date of [DATE], revealed Resident #4 was at risk for falls and was unable to use his upper extremities (hands/arms). The CP did not address interventions for staff assistance when ambulating. The CP noted Resident #4 had an Activities of Daily Living (ADL) deficit and would receive the following assistance: Extensive of two (2) to walk in room/corridor, extensive of one (1) for locomotion off unit, extensive of two (2) for toilet use, extensive of two (2) for transfers, and supervision of one (1) with locomotion on the unit. Extensive assistance is defined as the resident is involved in the activity, but staff provides weight-bearing support (having hands on the resident). Review of another Care Plan, provided by the facility on [DATE] at 2:05 PM, with a target date of [DATE], noted Resident #4 had an ADL deficit and would receive the following assistance: Limited of one (1) to walk in room/corridor, extensive of one (1) for locomotion off unit, extensive of two (2) for toilet use, extensive of two (2) for transfers and supervision of one (1) with locomotion on the unit. Review of a Care Plan, provided by the facility, dated [DATE], with a Target Date of [DATE], documented that Resident #4 required extensive assistance by two (2) persons with no resolved date listed, and also listed a resolved intervention of limited assist times one (1) person to walk in room/corridor with the resolved date of [DATE], on the day Resident #4 fell . Review of the Kardex/Care Plan, for the Certified Nursing Assistants (CNAs), from the admitted [DATE], and printed on [DATE], documented Resident #4 needed extensive assistance of two (2) staff to walk in room/corridor, extensive of two (2) staff for transfers, and extensive of two (2) for toilet use. The facility admitted Resident #4 on [DATE], with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the assessment date of [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 12, which indicated he was cognitively intact. Review of Resident #4's Fall Risk Screen, dated [DATE], revealed Resident #4 scored 11. The Fall Risk Screen assessment noted, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. This assessment was electronically signed by the Restorative Coordinator. Review of the Physical Therapy (PT) Progress and Discharge Summary, dated [DATE], revealed Resident #4 was discharged from PT and the goal was met with standing dynamic balance with documentation: Improving to Stand by assistance/close supervision (close enough to reach patient if assist needed). Review of a Progress Note, dated [DATE], revealed an entry by the Nurse Practitioner (NP) for Resident #4 that read: Reports he is no longer able to go to the bathroom without assistance due to muscle weakness in his legs. Review of a Fall Scene Investigation Report, dated [DATE] at 1:50 PM, unsigned, noted a witnessed fall to the floor while Resident #4 was standing at the bedside. This reported noted Resident #4 requested RN #1 to adjust his covers while he stood at the foot of the bed. A diagram of Resident #4's and RN #1's position was noted with RN #1 on the right side of the bed and Resident #4 on the left side of the bed. This report noted Resident #4 lost his balance while standing at the foot of the bed, with assistance to be increased with ambulation to two (2) persons. Review of the facility's Exception Report, dated [DATE], revealed Resident #4 lost his balance while standing, and fell on [DATE] at 1:50 PM. This report noted Resident #4 had bleeding from his head and ears after his fall and was in pain at a level of 10 on a scale from one (1) to 10, with 10 being the most severe. This report was signed by RN #1 on [DATE]. This report noted a statement by RN #1, that she was assisting Resident #4 back to bed when Resident #4 asked her to straighten his bed, and when she went around the bed, Resident #4 lost his balance and fell . Review of a Computerized Tomography (CT) scan, dated [DATE], for Resident #4 revealed: The study is significant for evidence of a hairline fracture left temporal bone extending into the external auditory canal with fluid possibly blood left external cord canal. Exam also shows what appears to be a very minimal amount of subarachnoid air in the posterior fossa on the left adjacent to the temporal bone. Review of the hospital Discharge Summary, dated [DATE], revealed Resident #4 died as a result of a Basilar Skull Fracture, fall at Nursing Home, and a Cerebral Contusion. Review of Resident #4's Certificate of Death, dated [DATE] at 4:54 AM, revealed the cause of death was Multi-organ Failure, due to Basilar Skull Fracture, as a consequence of a fall to the Floor. On [DATE] at 2:10 PM, in an interview, RN #1 confirmed Resident #4 had been assessed and care planned for (2) person assist for toileting. RN #1 stated that Resident #4 could usually stand alone, but confirmed Resident #4 could not use his arms at all, and when he started to fall, he could not hold his arms out to catch his fall. RN #1 confirmed Resident #4 was standing alone and no one was beside him when he fell . RN #1 confirmed the care plan was not followed. RN #1 was asked if she should have had someone in the room to help and she responded, Yes. If I could do it all over again I would. RN #1 stated that she was alone in the room at the time of the fall and called for help so they could get Resident #4 to the emergency room because he was bleeding out of both ears and head. During an observation, on [DATE] at 12:10 PM, while in the room where Resident #4 fell on [DATE], RN #1 demonstrated the distance from where she was standing and where Resident #4 was standing when the fall occurred, and was only able to touch the surveyors sleeve when attempting to reach across the bed to grab her arm. She stated she could not reach Resident #4 because it happened too fast. During an observation on [DATE] at 9:12 AM, measurements were obtained related to the distance RN #1 was from Resident #4 when he fell on [DATE], according to RN #1. With the Risk Manager present, the distance from the bathroom door to where RN #1 indicated she was standing was measured seven (7) feet. The distance from the bathroom door to where Resident #4 was standing measured six (6) feet. The standard bed measured 35 inches across and in the lowest position 22.5 inches in height. The distance measured, from Resident #4 to RN #1 was approximately 43 inches across. On [DATE] at 2:50 PM, Certified Nursing Assistant (CNA) #2, confirmed Resident #4 had problems with balance. She stated, His arms didn't work, so I had to help him sit up and also had to help him to the bathroom. He had to have two (2) people to help him to be safe because he couldn't help himself any, so I always asked for help. He couldn't grab anything if he started to fall and got off balance. She confirmed Resident #4's Kardex indicated the resident required assistance of staff due to his balance. On [DATE] at 2:55 PM, CNA #3 confirmed Resident #4 was unstable and required two (2) peopled to hold on to him to make sure he was stable, because he was unsteady with balance. On [DATE] at 3:04 PM, CNA #4 revealed Resident #4 came out of his room for activities and required, Two (2) people because he was unsteady and it was hard for him to keep his balance. CNA #4 stated Resident #4's Kardex (Care Plan) listed him as two (2) person assist because he was at risk for falls. During an interview on [DATE] at 11:34 AM, the Physical Therapist (PT) stated Resident #4 needed Contact Guard Assist with one (1) person with their hands on him while walking. He stated if Resident #4 was just standing in the room, he would need stand by assist, which means a person needs to be close enough to catch him in case he was to lose his balance. The PT confirmed Resident #4 did have episodes, during walking and standing, of losing his balance. Further interview with the PT on [DATE] at 1:00 PM, revealed Resident #4 was assessed for having someone in arms reach when standing alone, related to his loss of upper body use. The PT stated, He was flaccid, that put him at risk for not stopping his fall. The PT stated Resident #4 had been assessed and care planned this way during his whole stay at the facility. The PT stated Resident #4 was discharged from PT on [DATE], and the plan was for Contact Guard Assist (CGA) (Close enough to assist a resident if they began to fall) to stabilize him should he start to fall. During a phone interview on [DATE] at 10:17 AM, the facility Administrator at the time of Resident #4's fall on [DATE], stated Resident #4 had the right to stand alone. When asked if the facility had explained to Resident #4 the dangers of standing alone without assistance, as per his assessed plan of care, the Administrator stated she was not sure and would have to go back and look. During an interview on [DATE] at 1:50 PM, the Director of Nursing (DON) stated, Well she broke the rule is all I can say, when asked about RN's procedures during Resident #4's fall. The DON confirmed RN #1 assisted Resident #4 to the bathroom by herself, and confirmed Resident #4 was care planned for a two (2) person assist when being assisted to the bathroom. Further interview with the DON on [DATE] at 2:50 PM, revealed Resident #4's care plan was updated on [DATE], from one (1) person limited assistance when ambulating in the room/corridor to two (2) person physical assistance. The DON stated that if staff is not standing beside someone that is limited assist of (1) person physical assist, then they are not following the care plan of the Resident. On [DATE] at 8:31 AM, in an interview, Resident #4's Responsible Party (RP) revealed that during the admission process, the plan was that two (2) people would help Resident #4 at all times. The RP stated on the day Resident #4 fell , the facility told her that he was assisted by only one (1) person, the nurse taking him to the bathroom. The RP stated when she arrived to the emergency roiagnom on [DATE], Resident #4 told her that he kept telling the nurse, I'm falling, I'm falling, but she didn't try to stop him and he fell and busted his head open. The RP stated Resident #4 died on [DATE]. The Facility provided an acceptable Allegation of Compliance (AoC), which included: On [DATE] at 12:30 PM, the State Agency informed the Administrator, who started in the Administrator role on [DATE], of an Immediate Jeopardy with substandard quality of care, due to the facility's lack of supervision and failure to report a major injury of Resident #4. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 was care-planned at risk for falls and required assistance with most aspects of care. Resident #4's care plan dated [DATE], included: limited assistance times one (1) staff member for walking in room/corridor, supervision times one (1) staff member for locomotion on unit, extensive assistance times one (1) staff member for dressing, extensive assistance times one (1) staff member for eating, extensive assistance times one (1) staff member for locomotion off unit, extensive assistance times one (1) staff member for personal hygiene, extensive assistance times two (2) staff members for bathing, extensive assistance times two (2) staff members for bed mobility, extensive assistance times two (2) staff members for toilet use, and extensive assistance times two (2) staff members for transfers. Registered Nurse (RN) #1 did not follow the plan of care of Resident #4 who was extensive assistance times two (2) for toileting and transfers. Resident #4 had a Brief Interview for Mental Status (BIMS) of 12 as of [DATE], and participated in his plan of care. Resident #4 had a fall due to RN #1 was unable to catch Resident #4, and Resident #4 sustained a head injury on [DATE] at 1:50pm. Resident #4 was standing to the left side of his bed after being assisted from the bathroom by RN #1. Resident #4 requested that RN #1 straighten his covers on his bed to prepare for bed. RN #1 asked Resident #4 was he good to stand while she proceeded to walk to the opposite side of the bed. Resident #4 confirmed that he was stable with standing unassisted. RN #1 saw Resident #4 falling backwards and called out to him while reaching out towards him. RN #1 was not able to catch Resident #4 as he was falling. RN #1 immediately began to assess Resident #4 who was noted to be bleeding from back of head and ears. RN #1 kept Resident #4's C-spine stable as she alerted Housekeeper #1 and CNA #1 to alert additional nursing staff. LPN #1 called the ambulance at 1:50 PM and the ambulance arrived at the facility at 1:56 PM. LPN #1 notified the Responsible Party on [DATE] at 2:00 PM that Resident #4 had a fall with a head injury and was being transported to the local emergency room . The Unit Manager notified the Medical Director on [DATE] at 2:06 PM, that Resident #4 had a fall with a head injury and was being transported to the local emergency room . Resident #4 arrived to the local emergency roiagnom on [DATE] at 2:20 PM . Resident #4 was diagnosed with [REDACTED]. On [DATE] at 12:42 PM, the Responsible Party of Resident #4, notified the Assistant Director of Nursing (ADON) that Resident #4 expired on [DATE], while in the hospital. Resident #4's Death Certificate dated [DATE], states that Resident #4's cause of death was due to Multi-organ Failure, Basilar Skull Fracture, and fall to floor. Corrective Actions: 1. On [DATE] at 1:52 PM, the Risk Manager and ADON entered the room and initiated an investigation of Resident #4's fall. 2. On [DATE] at 3:00 PM, the Risk Manager completed an in-service with RN #1 regarding not following the care plan of extensive assistance times two (2) for toileting and transfers to prevent falls. 3. On [DATE] at 4:30 PM, the Risk Manager and Director of Nursing (DON) initiated a Quality Assurance Performance Improvement (QAPI) and Performance Improvement Project (PIP) to decrease falls with review of interventions to prevent accidents. Interventions included completing fall investigation after each fall, medication review after each fall, in-serviced all caregivers on reporting changes with Activity of Daily Living (ADL) support and following Kardex/Care plans, care plans to be reviewed and updated after each fall, and referrals will be made to therapy as needed. 4. On [DATE] at 1:45 PM, the Risk Manager held a scheduled annual in-service on preventing / reporting of abuse and neglect, completing exception reports, and resident rights. The following associates received this training: one (1) of one (1) Activity associates, three (3) of three (3) Maintenance associates, one (1) of one (1) Business Office Associates, 42 of 42 CNAs, 18 of 20 Licensed Practical Nurses (LPN), eight (8) of nine (9) RNs, 11 of 13 Dietary associates, and 12 of 12 Housekeeping/Laundry associates. 5. On [DATE] at 5:00 PM, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Risk Manager, Business Office Manager, Housekeeping Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinator, Restorative Coordinator, Unit Manager, Admission/Marketing Nurse, and Social Services Director to discuss the events after Resident #4's fall on [DATE], and the importance of reporting major injuries to state agencies within two (2) hours of occurrence. The QA Committee also reviewed policies on supervision and prevention of accidents, abuse/neglect, following care plan, and observing for change in condition. There were no changes made to current facility policies. 6. On the evening of [DATE], between 5:30 PM-9:00 PM, Nurse Managers including the Social Services Director, Unit Manager, Medicare Nurse, MDS Coordinator, Restorative Coordinator, Admissions/Marketing Nurse, and ADON audited 87 of 87 residents for needs of assistance with ADLs comparing a new fall risk screen to the individual resident's plan of care and Kardex. No discrepancies were noted and no changes were made to the care plan of the 87 residents audited. 7. On [DATE] at 5:30 PM through [DATE] at 11:45 AM, the Risk Manager and DON completed all in-services for all staff members on supervision and prevention of accidents, reporting requirements for major injuries, and following the care plan and updating plan of care upon a resident's change of condition. Nine (9) of nine (9) RNs, 20 of 20 LPNs, 42 of 42 CNAs, 13 of 13 Dietary associates, three (3) of three (3) Maintenance associates, 12 of 12 Housekeeping/Laundry associates, and seven (7) of seven (7) Therapy associates have been in-serviced. All new hires will receive this training during new hire orientation by the Risk Manager. 8. On [DATE] at 6:00 PM, the Pharmacy Consultant completed a pharmacy review of nine (9) residents who fell in (MONTH) 2019, with no concerns noted. 9. On [DATE] at 6:03 PM, the Risk Manager notified the State Licensing Agency of the completed investigation of Resident #4's fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 10. On [DATE] at 6:18 PM, the Risk Manager notified the Medicaid Fraud Control Unit (Attorney General) office that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 11. On [DATE] at 6:22 PM, the Risk Manager notified the local Police Department that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 12. On [DATE] at 12:10 PM, the Risk Manager audited all other Exception Reports since [DATE], for major injuries, with zero (0) of 142 Exception Reports resulting in major injuries. 13. The Administrator will report all results of the established monitoring to the Quality Assurance Committee meeting for the immediate corrective plan of action of any deficient practice. 14. No associate can work until they have received this in-service training. The facility alleges that all corrective actions were completed on [DATE], and Immediate Jeopardy removed as of [DATE]. Validation of the Allegation of Compliance included: The SA validated through record review and interview that Resident #4 was admitted on [DATE], with a [DIAGNOSES REDACTED]. The SA validated that Resident #4 fell on [DATE], after RN #1 assisted him to the toilet without assistance and left him standing, unassisted, as the foot of the bed while she went to the other side of the bed, out of arms reach of the resident. The SA validated Resident #4 was transferred to the hospital and diagnosed with [REDACTED]. The SA validated notification to the RP and the Medical Director. The SA validated the facility's Corrective Actions: 1. The SA validated through interviews and record review that on [DATE], the Risk Manager and ADON initiated an investigation of Resident #4's fall. 2. The SA validated through interviews and record review that on [DATE], the Risk Manager completed an in-service with RN #1 regarding not following the care plan of extensive assistance times two (2) for toileting and transfers to prevent falls. 3. The SA validated through interviews and record review that on [DATE], the Risk Manager and Director of Nursing (DON) initiated a Quality Assurance Performance Improvement (QAPI) and Performance Improvement Project (PIP) to decrease falls with review of interventions to prevent accidents. Interventions included completing fall investigation after each fall, medication review after each fall, in-serviced all caregivers on reporting changes with Activity of Daily Living (ADL) support and following Kardex/Care plans, care plans to be reviewed and updated after each fall, and referrals will be made to therapy as needed. 4. The SA validated through interviews and record review that on [DATE], the Risk Manager held a scheduled annual in-service on preventing/reporting of abuse and neglect, completing exception reports, and resident rights. The following associates received this training: one (1) of one (1) Activity associates, three (3) of three (3) Maintenance associates, one (1)of one (1) Business Office Associates, 42 of 42 CNAs, 18 of 20 Licensed Practical Nurses (LPN), eight (8) of nine (9) RNs, 11 of 13 Dietary associates, and 12 of 12 Housekeeping/Laundry associates. 5. The SA validated through interviews, sign-in sheets, and record review, that on [DATE], an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Risk Manager, Business Office Manager, Housekeeping Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinator, Restorative Coordinator, Unit Manager, Admission/Marketing Nurse, and Social Services Director to discuss the events after Resident #4's fall on [DATE], and the importance of reporting major injuries to state agencies within two (2) hours of occurrence. The QA Committee also reviewed policies on supervision and prevention of accidents, abuse/neglect, following care plan, and observing for change in condition. There were no changes made to current facility policies. 6. The SA validated through interviews and record review that on the evening of [DATE], Nurse Managers including the Social Services Director, Unit Manager, Medicare Nurse, MDS Coordinator, Restorative Coordinator, Admissions/Marketing Nurse, and ADON audited 87 of 87 residents for needs of assistance with ADLs, comparing a new fall risk screen to the individual resident's plan of care and Kardex. No discrepancies were noted and no changes were made to the care plan of the 87 residents audited. 7. The SA validated through interviews and record review on [DATE], through [DATE], the Risk Manager and DON completed all in-services for all staff members on supervision and prevention of accidents, reporting requirements for major injuries, and following care plan and updating plan of care upon a resident's change of condition. Nine (9) of (9) RNs, 20 of 20 LPNs, 42 of 42 CNAs, 13 of 13 Dietary associates, three (3) of (3) Maintenance associates, 12 of 12 Housekeeping/Laundry associates, and seven (7) of (7) Therapy associates have been in-serviced. The SA validated that all new hires will receive this training during new hire orientation by the Risk Manager. 8. The SA validated through interviews and record review that on [DATE], the Pharmacy Consultant completed a pharmacy review of nine (9) residents who fell in (MONTH) 2019, with no concerns noted. 9. The SA validated through interviews and record review on [DATE], the Risk Manager notified the State Licensing Agency of the completed investigation of Resident #4's fall on [DATE], which resulted in death on [DATE] due to Multi-organ Failure and Basilar Skull Fracture. 10. The SA validated through interviews and record review on [DATE], the Risk Manager notified the Medicaid Fraud Control Unit (Attorney General) office that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 11. The SA validated through interviews and record review on [DATE] at 6:22, the Risk Manager notified the local Police Department that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 12. The SA validated through interviews and record review on [DATE], the Risk Manager audited all other Exception Reports since [DATE], for major injuries with zero (0) of 142 Exception Reports resulting in major injuries. 13. The SA validated through interview the Administrator will report all results of the established monitoring to the Quality Assurance Committee meeting for the immediate corrective plan of action of any deficient practice. 14. The SA validated through interviews and record review that no associate worked until they had received this in-service training. The SA validated that all corrective actions were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].

CI MS # Based on observation, interviews, record review, and facility statement, the facility failed to provide adequate assistance as assessed and care planned, to prevent an accident, which resulted in major injury/death, for one (1) of seven (7) residents reviewed, Resident #4. Resident #4 was assessed and care planned for two (2) person assistance with toileting and transfer, and one (1) person assistance for mobility. Resident #1 fell and received a Head Injury and Skull Fracture when Registered Nurse (RN) #1 was unable to reach him when he became unbalanced, while left unassisted at the bedside. RN #1 assisted Resident #4 to the bathroom by herself on [DATE], then left the resident on one (1) side of the bed while she went to the other side to adjust his bed covers. RN #1 was approximately 43 inches away from Resident #4, with the resident's bed between them, when Resident #4, who was left standing alone, fell and hit his head on the floor. Resident #4 sustained a head injury and skull fracture on [DATE], and died on [DATE]. The death certificate listed the cause of death as Multi-organ Failure, Basilar Skull Fracture, and fall to the floor. Resident #4 had a [DIAGNOSES REDACTED]. The facility's failure to provide supervision/assistance, per assessment and care plan, to prevent accidents and hazards, resulted in the injury and death of Resident #4 , and placed other residents assessed/care planned for transfer/mobility assistance, in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), that began on [DATE], when Resident #4 fell , while left standing alone, and RN #1 was not close enough to provide assistance to break and/or prevent his fall. On [DATE] at 12:30 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ removed on [DATE]. The SA validated the A[NAME], and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.25 (d)(1)(2)-Free of Accidents/Supervision/Devices, F689, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of a post exit statement on letterhead, from the Director of Nursing (DON) on [DATE], revealed the facility did not have a policy in place for assessing residents for preventing accident/hazards with known assistance needs. This statement noted the facility performs Fall Risk Screens on admission and quarterly to determine fall risks. The facility admitted Resident #4 on [DATE], with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 12, and was cognitively intact. A review of Resident #4's Fall Risk Screen, dated [DATE], revealed Resident #4 scored 11. The Fall Risk Screen assessment noted, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. This assessment was electronically signed by the Restorative Coordinator, Licensed Practical Nurse (LPN). Review of the Physical Therapy (PT) Progress and Discharge Summary, dated [DATE], revealed Resident #4 was discharged from PT and required, Stand by assistance/close supervision (close enough to reach patient if assist needed). Review of the Physician's Progress Notes, for Resident #4, dated [DATE], revealed an entry which noted the resident reported he is no longer able to go to the bathroom without assistance due to muscle weakness in his legs. This note was signed by the Nurse Practitioner (NP). A review of the Care Plan, dated [DATE], with a target date of [DATE], revealed Resident #4 was at risk for falls, with no interventions related to staff assistance when ambulating. This Care Plan also noted Resident #4 had an Activities of Daily Living (ADL) Deficit and would receive the following assistance: Extensive assistance of two (2) persons to walk in the room/corridor, extensive assistance of one (1) person for locomotion off the unit, extensive assistance of two (2) persons for toilet use, extensive assistance of two (2) persons for transfers, and supervision of one (1) person with locomotion on the unit. Review of a second Care Plan, dated [DATE], with the same Target Date of [DATE], listed that Resident #4 required extensive assistance by two (2) persons with no resolved date listed, and also listed a resolved intervention of limited assist of one (1) person to walk in the room/corridor, with the resolved date of [DATE], on the day Resident #4 fell . Extensive assistance requires staff holding on to the resident and doing most of the task. Limited assistance requires hands on, but resident doing most of the task. Supervision requires that staff is available and guiding/cueing the resident to do a task. A review of the facility's Fall Scene Investigation Report, dated [DATE] at 1:50 PM, unsigned, documented Resident #4 fell to the floor while standing at the bedside. The resident was noted alert and oriented. This report noted Resident #4 requested RN #1 to adjust his covers while he stood at the foot of the bed. A diagram, of Resident #4's and RN #1's position was documented, with RN #1 on the right side of the bed, and Resident #4 on the left side of the bed. This report noted Resident #4 lost his balance while standing at the foot of the bed. The report documented assistance was increased to two (2) persons for ambulation. A review of the facility's Exception Report, dated [DATE], revealed Resident #4 lost his balance, on [DATE] at 1:50 PM, while standing. This report noted Resident #4 had bleeding from his head and ears after his fall and was in pain at a level of 10, on a scale from one (1) to 10, with 10 being the most severe. This report was signed by RN #1 on [DATE]. This report noted a statement by RN #1, which revealed she was assisting Resident #4 back to bed when Resident #4 asked her to straighten his bed and when she went around the bed, Resident #4 lost his balance and fell . Review of the Ambulance report, dated [DATE], revealed Resident #4 was found in the floor, alert and oriented x 4 (person, place, time, situation). The report noted the Patient had a blood pool behind his head and was bleeding from the left ear. The report documented that Resident #4 stated the staff stood him up and dropped him. The report documented the resident had a laceration/hematoma to the back of the skull and bleeding from the ear. The resident was transported to the hospital. Review of Resident #4's Computerized Tomography (CT) scan, dated [DATE], revealed, The study is significant for evidence of a hairline fracture left temporal bone extending into the external auditory canal with fluid possibly blood left external cord canal. Exam also shows what appears to be a very minimal amount of subarachnoid air in the posterior fossa on the left adjacent to the temporal bone. Review of the hospital Discharge Summary, with a discharge date of [DATE], revealed Resident #4 expired on [DATE], as a result of a Basilar Skull Fracture, fall at the Nursing Home, and a Cerebral Contusion. A review of Resident #4's Certificate of Death, dated [DATE] at 4:54 AM, revealed the cause of death was Multi-organ Failure, due to Basilar Skull Fracture, as a consequence of a fall to the Floor. In an interview on [DATE] at 2:10 PM, RN #1 stated that on [DATE], she assisted Resident #4 to the bathroom and he wanted his bed straightened. RN #1 stated that she stood Resident #4 by the bathroom door and asked him if he was okay, and he stated he was. RN #1 stated she was straightening Resident #4's bed and when she looked up, Resident #4 was falling. RN #1 stated that she could not get to Resident #4 in time to catch him and he fell , hitting his head on the floor. RN #1 confirmed that she was alone in the room at the time and called for help, so they could get him to the emergency room (ER), because Resident #4 was bleeding out of both ears and head. RN #1 confirmed Resident #4 had been assessed and care planned for (2) person assistance for toileting. RN #1 stated that Resident#4 could usually stand alone, but confirmed Resident #4 could not use his arms at all, and when he started to fall, he could not hold his arms out to catch anything. She stated the resident could not catch himself. RN #1 confirmed Resident #4 was standing alone and no one was beside him when he fell . RN #1 was asked if she should have had someone in the room to help, and responded, Yes, if I could do it all over again I would. In an interview and observation on [DATE] at 12:00 PM-12:10 PM, RN #1 revealed Resident #4 was on the left side of the bed in front of the bathroom door and was approximately two (2) feet from the end of the bed when he fell . RN #1 demonstrated the distance from where she was standing and where Resident #4 was standing when the fall occurred on [DATE], in the resident's room. RN #1 was only able to touch the surveyor's sleeve when attempting to reach across the bed, where she indicated Resident #4's position was on the day of the fall. She stated she could not reach Resident #4, because it happened too fast. During an observation on [DATE] at 9:12 AM, measurements were obtained with the Risk Manager present, as to the location (identified by RN #1) of Resident #4 and RN #1, when Resident #4 fell on [DATE]. The distance from the bathroom door to where RN #1 indicated she was standing, was measured at seven (7) feet. The distance from the bathroom door to where Resident #4 was standing measured six (6) feet. The standard bed measured 35 inches across and in the lowest position 22.5 inches in height. The distance measured, from the location RN #1 had indicated both she and the resident was located prior to his fall, was 43 inches across. In an interview, on [DATE] at 2:50 PM, Certified Nursing Assistant (CNA) #2 stated Resident #4's arms didn't work, so she had to help him sit up and also had to help him to the bathroom. The CNA stated the resident had to have two (2) people to help him to be safe, because he couldn't help himself any, so she always asked for help. The CNA stated the resident couldn't grab anything if he started to fall and got off balance. CNA #2 confirmed Resident #4 had concerns with keeping his balance. In an interview on [DATE] at 2:55 PM, CNA #3 revealed Resident #4 required two (2) person assistance to go to the bathroom and she would help the assigned CNA. CNA #3 stated, Nobody walked him by himself, there was always two (2) of us to hold onto him to make sure he was stable. CNA #3 confirmed Resident #4 was unsteady on his feet. In an interview on [DATE] at 3:04 PM, CNA #4 revealed that Resident #4 came out of his room for activities. The CNA stated Resident #4 required two (2) people for assistance, because he was unsteady and it was hard for him to keep his balance. CNA #4 stated Resident #4 required two (2) person assist, because he was at risk for falls. In an interview on [DATE] at 11:34 AM, the Physical Therapist (PT) revealed Resident #4 was a one (1) person assist with walking and this was mainly because he didn't have much control over his upper extremity, and his balance. The PT stated Resident #4 was Contact Guard Assist with one (1) person with their hands on him while walking, and if Resident #4 was just standing in the room, he would need stand by assist, which means a person needs to be close enough to catch him in case he was to lose his balance. The PT confirmed Resident #4 did have episodes, while walking, of losing his balance. The PT stated when standing, someone always stood by Resident #4, in case he lost his balance. When asked if Resident #4 was safe to stand alone, the PT replied, Only if you are close enough to catch him if he lost his balance. Further interview with the PT on [DATE] at 1:00 PM, confirmed Resident #4 was assessed for having someone in arms reach when standing alone, related to his loss of upper body use. The PT stated, He was flaccid, that put him at risk for not stopping his fall. The PT stated Resident #4 was discharged from PT on [DATE], and was on Contact Guard Assist (CGA), which means staff are close enough to assist and stabilize a resident if they began to fall. The PT stated in regards to Resident #4's condition, With loss of upper body function, balance would always be a problem. I can't say what happened, but balance was a concern. Interview with Resident #4's Primary Care Physician (PCP)/Medical Director on [DATE] at 10:30 AM, reveled he had been notified that Resident #4 had a fall with a brain bleed, skull fracture, and later death. The PCP stated he was notified there was only one (1) nurse in the room when the resident fell . The PCP stated he was not sure if there was supposed to be more assistance in the room, but Resident #4 had no use of his arms, related to his ALS/Lou Gehrig's disease diagnosis, and was declining in status. During an interview on [DATE] at 10:17 AM, the facility Administrator at the time of Resident #4's fall on [DATE], stated the investigation revealed the nurse, (RN #1), had helped Resident #4 to the bathroom, walked back to the bed, and Resident #4 requested RN #1 straighten his bed linens. The Administrator stated RN #1 said she asked the resident if he was okay to stand, and RN #1 reported the Resident said that he was. The Administrator stated it was reported that Resident #4 was on the left side of the bed from the foot, and the nurse was on the right side of the bed from the foot, and when RN #1 looked up, Resident #4 was falling. The Administrator stated the Nurse could not get to Resident #4 in time to catch him; he fell to the floor, hitting his head. The Administrator stated Resident #4 had the right to stand alone. When asked if the facility had explained to Resident #4 the dangers of standing alone, without assistance, as per his assessed plan of care, the Administrator stated she was not sure and would have to look. When asked if the nurse was on one (1) side of the bed, and the resident on the other, was that considered one (1) person assistance, the Administrator stated, I don't know. The Administrator stated that Resident #4 was one (1) person assist with ambulation, and two (2) person assist when toileting. The Administrator responded that she did not know if any staff was holding on to the resident, or within arm's length, when he fell . In an interview on [DATE] at 1:50 PM, the Director of Nursing (DON) stated of RN #1, Well she broke the rule is all I can say. The DON confirmed RN #1 was assisting Resident #4 to the bathroom by herself, and confirmed Resident #4 was assessed and care planned for two (2) person assistance with toileting. In an interview on [DATE] at 2:50 PM, the DON stated Resident #4 was at risk for falls due to the (ALS) diagnosis, and did not have use of his upper extremities. She stated if staff was not standing right beside someone, who required limited assistance of one (1) person, then they were not following the care plan of the Resident. Further interview with the DON on [DATE] at 9:30 AM, revealed when Resident #4 fell on [DATE], that RN #1 should have been holding on to him. Interview with Resident #4's Responsible Party (RP) on [DATE] at 8:31 AM, revealed during the admission process it was discussed that two (2) people would help Resident #4 at all times. She stated on the day Resident #4 fell , she was told that only one (1) person, the nurse, assisted him to the bathroom. The RP stated when she arrived at the emergency roiagnom on [DATE], Resident #4 was still awake and told her that he kept telling the nurse, I'm falling, I'm falling, but that she didn't try to stop him and he fell , busting his head open. The RP stated she returned to the facility on [DATE], the day Resident #4 died , and notified the facility that he had expired. In a post exit interview on [DATE] at 10:54 AM, the Nurse Practitioner (NP) stated she alternated visits with the PCP and recalled the progress notes regarding Resident #4. She stated she remembered this resident specifically because of his [DIAGNOSES REDACTED]. The NP stated when she first saw Resident #4, he was able to walk some, but reported on the last visit that he had progressive weakness to his legs and was unable to go to the bathroom without assistance. The NP stated, because of the Lou Gehrig's disease, he would have only gotten worse, not better. The Facility provided an acceptable Allegation of Compliance (AoC), which included: On [DATE] at 12:30 PM, the State Agency informed the Administrator, who started in the Administrator role on [DATE], of an Immediate Jeopardy with substandard quality of care, due to the facility's lack of supervision and failure to report a major injury of Resident #4. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 was care-planned at risk for falls and required assistance with most aspects of care. Resident #4's care plan dated [DATE], included: limited assistance times one (1) staff member for walking in room/corridor, supervision times one (1) staff member for locomotion on unit, extensive assistance times one (1) staff member for dressing, extensive assistance times one (1) staff member for eating, extensive assistance times one (1) staff member for locomotion off unit, extensive assistance times one (1) staff member for personal hygiene, extensive assistance times two (2) staff members for bathing, extensive assistance times two (2) staff members for bed mobility, extensive assistance times two (2) staff members for toilet use, and extensive assistance times two (2) staff members for transfers. Registered Nurse (RN) #1 did not follow the plan of care of Resident #4 who was extensive assistance times two (2) for toileting and transfers. Resident #4 had a Brief Interview for Mental Status (BIMS) of 12 as of [DATE], and participated in his plan of care. Resident #4 had a fall due to RN #1 was unable to catch Resident #4, and Resident #4 sustained a head injury on [DATE] at 1:50 PM. Resident #4 was standing to the left side of his bed after being assisted from the bathroom by RN #1. Resident #4 requested that RN #1 straighten his covers on his bed to prepare for bed. RN #1 asked Resident #4 was he good to stand while she proceeded to walk to the opposite side of the bed. Resident #4 confirmed that he was stable with standing unassisted. RN #1 saw Resident #4 falling backwards and called out to him while reaching out towards him. RN #1 was not able to catch Resident #4 as he was falling. RN #1 immediately began to assess Resident #4 who was noted to be bleeding from back of head and ears. RN #1 kept Resident #4's C-spine stable as she alerted Housekeeper #1 and CNA #1 to alert additional nursing staff. LPN #1 called the ambulance at 1:50 PM and the ambulance arrived at the facility at 1:56 PM. LPN #1 notified the Responsible Party on [DATE] at 2:00 PM that Resident #4 had a fall with a head injury and was being transported to the local emergency room . The Unit Manager notified the Medical Director on [DATE] at 2:06 PM, that Resident #4 had a fall with a head injury and was being transported to the local emergency room . Resident #4 arrived to the local emergency roiagnom on [DATE] at 2:20 PM . Resident #4 was diagnosed with [REDACTED]. On [DATE] at 12:42 PM, the Responsible Party of Resident #4, notified the Assistant Director of Nursing (ADON) that Resident #4 expired on [DATE], while in the hospital. Resident #4's Death Certificate dated [DATE], states that Resident #4's cause of death was due to Multi-organ Failure, Basilar Skull Fracture, and fall to floor. Corrective Actions: 1. On [DATE] at 1:52 PM, the Risk Manager and ADON entered the room and initiated an investigation of Resident #4's fall. 2. On [DATE] at 3:00 PM, the Risk Manager completed an in-service with RN #1 regarding not following the care plan of extensive assistance times two (2) for toileting and transfers to prevent falls. 3. On [DATE] at 4:30 PM, the Risk Manager and Director of Nursing (DON) initiated a Quality Assurance Performance Improvement (QAPI) and Performance Improvement Project (PIP) to decrease falls with review of interventions to prevent accidents. Interventions included completing fall investigation after each fall, medication review after each fall, in-serviced all caregivers on reporting changes with Activity of Daily Living (ADL) support and following Kardex/Care plans, care plans to be reviewed and updated after each fall, and referrals will be made to therapy as needed. 4. On [DATE] at 1:45 PM, the Risk Manager held a scheduled annual in-service on preventing / reporting of abuse and neglect, completing exception reports, and resident rights. The following associates received this training: one (1) of one (1) Activity associates, three (3) of three (3) Maintenance associates, one (1) of one (1) Business Office Associates, 42 of 42 CNAs, 18 of 20 Licensed Practical Nurses (LPN), eight (8) of nine (9) RNs, 11 of 13 Dietary associates, and 12 of 12 Housekeeping/Laundry associates. 5. On [DATE] at 5:00 PM, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Risk Manager, Business Office Manager, Housekeeping Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinator, Restorative Coordinator, Unit Manager, Admission/Marketing Nurse, and Social Services Director to discuss the events after Resident #4's fall on [DATE], and the importance of reporting major injuries to state agencies within two (2) hours of occurrence. The QA Committee also reviewed policies on supervision and prevention of accidents, abuse/neglect, following care plan, and observing for change in condition. There were no changes made to current facility policies. 6. On the evening of [DATE], between 5:30 PM-9:00 PM, Nurse Managers including the Social Services Director, Unit Manager, Medicare Nurse, MDS Coordinator, Restorative Coordinator, Admissions/Marketing Nurse, and ADON audited 87 of 87 residents for needs of assistance with ADLs comparing a new fall risk screen to the individual resident's plan of care and Kardex. No discrepancies were noted and no changes were made to the care plan of the 87 residents audited. 7. On [DATE] at 5:30 PM through [DATE] at 11:45 AM, the Risk Manager and DON completed all in-services for all staff members on supervision and prevention of accidents, reporting requirements for major injuries, and following the care plan and updating plan of care upon a resident's change of condition. Nine (9) of nine (9) RNs, 20 of 20 LPNs, 42 of 42 CNAs, 13 of 13 Dietary associates, three (3) of three (3) Maintenance associates, 12 of 12 Housekeeping/Laundry associates, and seven (7) of seven (7) Therapy associates have been in-serviced. All new hires will receive this training during new hire orientation by the Risk Manager. 8. On [DATE] at 6:00 PM, the Pharmacy Consultant completed a pharmacy review of nine (9) residents who fell in (MONTH) 2019, with no concerns noted. 9. On [DATE] at 6:03 PM, the Risk Manager notified the State Licensing Agency of the completed investigation of Resident #4's fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 10. On [DATE] at 6:18 PM, the Risk Manager notified the Medicaid Fraud Control Unit (Attorney General) office that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 11. On [DATE] at 6:22 PM, the Risk Manager notified the local Police Department that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 12. On [DATE] at 12:10 PM, the Risk Manager audited all other Exception Reports since [DATE], for major injuries, with zero (0) of 142 Exception Reports resulting in major injuries. 13. The Administrator will report all results of the established monitoring to the Quality Assurance Committee meeting for the immediate corrective plan of action of any deficient practice. 14. No associate can work until they have received this in-service training. The facility alleges that all corrective actions were completed on [DATE], and Immediate Jeopardy removed as of [DATE]. Validation of the Allegation of Compliance included: The SA validated through record review and interview that Resident #4 was admitted on [DATE], with a [DIAGNOSES REDACTED]. The SA validated that Resident #4 fell on [DATE], after RN #1 assisted him to the toilet without assistance and left him standing, unassisted, as the foot of the bed while she went to the other side of the bed, out of arms reach of the resident. The SA validated Resident #4 was transferred to the hospital and diagnosed with [REDACTED]. The SA validated notification to the RP and the Medical Director. The SA validated the facility's Corrective Actions: 1. The SA validated through interviews and record review that on [DATE], the Risk Manager and ADON initiated an investigation of Resident #4's fall. 2. The SA validated through interviews and record review that on [DATE], the Risk Manager completed an in-service with RN #1 regarding not following the care plan of extensive assistance times two (2) for toileting and transfers to prevent falls. 3. The SA validated through interviews and record review that on [DATE], the Risk Manager and Director of Nursing (DON) initiated a Quality Assurance Performance Improvement (QAPI) and Performance Improvement Project (PIP) to decrease falls with review of interventions to prevent accidents. Interventions included completing fall investigation after each fall, medication review after each fall, in-serviced all caregivers on reporting changes with Activity of Daily Living (ADL) support and following Kardex/Care plans, care plans to be reviewed and updated after each fall, and referrals will be made to therapy as needed. 4. The SA validated through interviews and record review that on [DATE], the Risk Manager held a scheduled annual in-service on preventing/reporting of abuse and neglect, completing exception reports, and resident rights. The following associates received this training: one (1) of one (1) Activity associates, three (3) of three (3) Maintenance associates, one (1)of one (1) Business Office Associates, 42 of 42 CNAs, 18 of 20 Licensed Practical Nurses (LPN), eight (8) of nine (9) RNs, 11 of 13 Dietary associates, and 12 of 12 Housekeeping/Laundry associates. 5. The SA validated through interviews, sign-in sheets, and record review, that on [DATE], an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Risk Manager, Business Office Manager, Housekeeping Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinator, Restorative Coordinator, Unit Manager, Admission/Marketing Nurse, and Social Services Director to discuss the events after Resident #4's fall on [DATE], and the importance of reporting major injuries to state agencies within two (2) hours of occurrence. The QA Committee also reviewed policies on supervision and prevention of accidents, abuse/neglect, following care plan, and observing for change in condition. There were no changes made to current facility policies. 6. The SA validated through interviews and record review that on the evening of [DATE], Nurse Managers including the Social Services Director, Unit Manager, Medicare Nurse, MDS Coordinator, Restorative Coordinator, Admissions/Marketing Nurse, and ADON audited 87 of 87 residents for needs of assistance with ADLs, comparing a new fall risk screen to the individual resident's plan of care and Kardex. No discrepancies were noted and no changes were made to the care plan of the 87 residents audited. 7. The SA validated through interviews and record review on [DATE], through [DATE], the Risk Manager and DON completed all in-services for all staff members on supervision and prevention of accidents, reporting requirements for major injuries, and following care plan and updating plan of care upon a resident's change of condition. Nine (9) of (9) RNs, 20 of 20 LPNs, 42 of 42 CNAs, 13 of 13 Dietary associates, three (3) of (3) Maintenance associates, 12 of 12 Housekeeping/Laundry associates, and seven (7) of (7) Therapy associates have been in-serviced. The SA validated that all new hires will receive this training during new hire orientation by the Risk Manager. 8. The SA validated through interviews and record review that on [DATE], the Pharmacy Consultant completed a pharmacy review of nine (9) residents who fell in (MONTH) 2019, with no concerns noted. 9. The SA validated through interviews and record review on [DATE], the Risk Manager notified the State Licensing Agency of the completed investigation of Resident #4's fall on [DATE], which resulted in death on [DATE] due to Multi-organ Failure and Basilar Skull Fracture. 10. The SA validated through interviews and record review on [DATE], the Risk Manager notified the Medicaid Fraud Control Unit (Attorney General) office that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 11. The SA validated through interviews and record review on [DATE] at 6:22, the Risk Manager notified the local Police Department that Resident #4 had a fall on [DATE], which resulted in death on [DATE], due to Multi-organ Failure and Basilar Skull Fracture. 12. The SA validated through interviews and record review on [DATE], the Risk Manager audited all other Exception Reports since [DATE], for major injuries with zero (0) of 142 Exception Reports resulting in major injuries. 13. The SA validated through interview the Administrator will report all results of the established monitoring to the Quality Assurance Committee meeting for the immediate corrective plan of action of any deficient practice. 14. The SA validated through interviews and record review that no associate worked until they had received this in-service training. The SA validated that all corrective actions were completed on [DATE], and the Immediate Jeopardy removed as of [DATE].

Based on record review, staff interview and facility policy review, the facility failed to transmit the resident assessment in a timely manner for one (1) of (23) Minimum Data Set (MDS) assessments reviewed, for Resident #1. Findings Include: A Review of the facilities policy titled, MDS Submissions, dated (MONTH) 2010, revealed our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The assessment coordinator or designee will be responsible for ensuring that all resident assessments completed are transmitted on a timely basis. Record review of Resident #1's Minimum Data Set (MDS) revealed it was completed on 7/30/2018, but was not transmitted to the Centers for Medicare and Medicaid services (CMS). Interview on 10/10/2018 at 12:34 PM with Licensed Practical ( LPN) #1/MDS Nurse confirmed the MDS was completed on 7/30/2018, but was not transmitted. LPN #1/MDS Nurse stated the facility missed it. LPN #1/MDS Nurse could not give an explanation of why the assessment was not transmitted. LPN #1/MDS Nurse said they don't have this to happen often. LPN #1/MDS Nurse said the facility has done a 100% audit on all assessments to make sure they have all been transmitted. LPN #1/MDS Nurse said the MDS Nurses are responsible for ensuring the resident assessments are submitted to the CMS MDS database in a timely manner according to the MDS RAI manual. An interview, on 10/10/2018 at 12:53 PM, with the Director of Nursing (DON) confirmed the facility failed to transmit Resident #1's MDS assessment on 7/30/2018. The Don stated she did not know what happened. A review of the facility's Admission Record revealed the facility admitted Resident #1, on 02/15/2016 with [DIAGNOSES REDACTED]. A review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2018, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident was cognitively impaired.