Every finding on record at Providence Pointe Healthcare

Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate supervision and assistive devices to ensure the safety of its residents for 1 of 9 sampled residents (Resident (R)9). The findings include: Review of the facility policy titled, Safety and Supervision of Residents, revised 07/2017, revealed the interdisciplinary team (IDT) was to analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Further review of the policy revealed the IDT care team was to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility policy titled, Managing Fall and Fall Risk, revised 03/2018, revealed the facility should develop a resident-centered fall prevention plan in effort to reduce identified risk factor(s) of falls for each resident at risk or with a history of falls. Futher review of the policy revealed if falling recurred despite initial interventions, staff were to implement additional or different interventions, or indicate why the current approach remained relevant. Review of the facesheet for R9 revealed the facility admitted the resident on 05/14/2025, with diagnoses that included urinary tract infection, traumatic brain injury, unsteadiness on feet, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R9 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Review of the progress note dated 05/15/2025 at 10:27 AM, revealed R9 had been restless all morning and attempted to get out of bed to mow and continued to pull at abdominal binder and percutaneous endoscopic gastrostomy (PEG) tube. Review of the progress note dated 05/16/2025 at 11:51 PM, revealed R9 had been found lying on the floor in front of his wheelchair at 6:30 PM on 05/15/2026. Continued review revealed R9 had been unable to give a description of what happened due to confusion. Further review of the progress note revealed R9 stated he hit his head. In addition, review revealed R9 was sent to the emergency room (ER) for evaluation due to his history of a brain bleed. Review of the facility document titled, FSI Fall Scene Investigation Report,dated 05/16/2025, revealed the contributing factors of R9's fall were the amount of assistance in effect and mood or mental status. Further review of the document revealed the care plan had been updated, with the addition of a perimeter defining mattress. Review of the facility document titled, FSI Fall Scene Investigation Report dated 05/17/2025, revealed R9 sustained a fall on 05/17/2025 at 6:00 PM when the nurse observed the resident sliding out of bed onto the floor after he had been trying to get out of bed unassisted all shift. Per review, the contributing factors of the fall were noted as confusion related to a history of traumatic brain injury. Continued review revealed the document listed the initial intervention to prevent falls as being Fall mat placed to right side of bed. Further review of the document revealed the care plan had been updated with the addition of a fall mat on the floor on the right side of R9's bed. Review of the progress note dated 05/17/2025 at 8:38 PM, revealed R9 had been found in his room sitting on the bed, and had pulled his PEG tube out and the PEG tube was lying on the floor beside his continuous positive airway pressure (CPAP) machine. The PEG site was noted to be bleeding and R9 had been confused and hallucinating. Further review of the progress note revealed R9 was taken to the ER via EMS to be evaluated. Review of the progress note dated 05/23/2025 at 11:55 PM, revealed R9 continued to be confused and pulled his abdominal binder off and pulled on his PEG tube. Review of the IDT note dated 05/29/2025 at 3:35 PM, revealed R9 sustained a fall on 05/28/2025 at 7:55 PM. Per review of the note, R9 had been found lying on his back on the floor between his bed and the window with no injuries noted. Review of the facility document titled, FSI Fall Scene Investigation Report dated 05/28/2025, revealed the contributing factors to R9's fall were mood and mental status. Further review of the document revealed the resident' scare plan was revised with the addition of changing the room configuration with the right side of the bed against the wall. Review of the facility document titled, FSI Fall Scene Investigation Report, dated 05/29/2025, revealed R9 had an unwitnessed fall on 05/29/2025 at 9:05 PM. Per review, R9 fell across from the nurse's station, while attempting to transfer from his wheelchair to a regular chair and tripped over the foot rests of wheelchair. Continued review revealed staff had placed R9 in the wheelchair across from the nurse's station so they could keep an eye on the resident. Further review of the document revealed R9's care plan had been updated with the addition of removing the leg rests when sitting in his wheelchair. Review of the facility document titled, FSI Fall Scene Investigation Report, dated 06/03/2025, revealed R9 had an unwitnessed fall on 06/03/2025 at 6:30 AM. Per review, R9 had been found crawling in the hallway without a brief on and told staff he was looking for his puppy that got out of the house. Continued review revealed the contributing factor to fall R9's had been confusion. Further review of the document revealed R9's care plan had been updated with the addition of offering the resident a stuffed puppy for comfort. Review of the health status note dated 06/03/2025 at 10:45 AM, revealed the 300-hall Unit Manager (UM) documented speaking with R9's wife about the resident's frequent falls, anxiety, and not being able to sit still. Per review, the UM noted suggesting to the family they get a sitter or come spend more time in the facility with R9. Further review revealed R9's wife told the UM she was not able to provide a sitter or spend more time in the facility. Review of the facility document titled, FSI Fall Scene Investigation Report dated 06/06/2025, revealed R9 sustained a fall. Per review, on 06/06/2025 at 11:15 AM, the resident fell out of his wheelchair onto the floor while in the dining room attempting to self-transfer. Further review of the document revealed R9's care plan was updated with the addition of anti- roll backs placed on the wheelchair. Continued review of R9's electronic health record (EHR) revealed the resident was hospitalized on [DATE] due to pulling out his PEG tube earlier that morning. Review further revealed R9 returned to the facility at approximately 3:00 PM on 06/11/2025 after having the PEG tube replaced. Observation on 06/12/2025 at 8:30 AM, of R9 in his room revealed the resident lying on the bed with eyes closed and a one-to-one (1:1) supervision person present. Review of the 1:1 sitter logs for R9 revealed the resident had been on 1:1 supervision since 06/11/2025 at 3:30 PM (approximately the time he returned from the hospital). In interview with the Physical Therapy Assistant (PTA) 1 on 06/11/2025 at 9:30 AM, she stated she only treated R9 one time, and that had been for in-room treatment. She said R9 had not wanted to participate in the therapy. PTA 1 explained she had to get R9's wife to help him to participate in his therapy. She further stated that physical therapy was usually only helpful with improvement if the resident was able to follow direction and consistency. In interview on 06/11/2025 at 9:45 AM, the medical Nurse Practitioner (NP) stated R9 was on of her patients in conjunction with the doctor. She stated she had not been able to get a lot of information from R9 as he was not cognitive intact. The NP reported calling R9's wife to speak with her and a family friend about the resident. She said since R9 has been at the facility he had been pulled out his feeding tube a couple of times. The NP explained they had used an abdominal binder to keep R9's feeding tube out of reach. She stated as R9 had kept wheeling his wheelchair while attached to his feeding pump, they had changed his tube feedings to bolus feeding to keep him from pulling at it. The NP reported to her knowledge, R9 has not fallen, but had been found crawling on the floor. She stated the family wanted the facility to use restraints, such as side rails and lap buddies; however, they never ordered restraints at the facility. The NP said resident rights indicated a resident had the right to be free from restraints and also had the right to fall. She explained she asked the doctor for more information on all the options for R9 and said she did not think the resident was a good fit for the facility. The NP reported she thought R9 needed more 1:1 care. She stated she did not want to chemically restrain R9, but he would be better off if we can just keep him calm. The NP said R9's Exelon patch and Namenda (used to treat Alzheimer's disease), and his Buspar (an anti-anxiety medication) had all been increased. She further stated she thought the staff at the facility were really good about figuring out the cause of residents' falls and putting necessary interventions in place. In interview with Certified Nursing Assistant (CNA) 6 on 06/11/2025 at 10:33 AM, she stated she normally worked in restorative care, and was not familiar with R9. She stated typical fall prevention interventions used at the facility included placing mats on the floor by the bed in a resident's room; putting up signs in their room to remind them to use their call light; and rearranging items in the room to facilitate safer movement. CNA 6 said seatbelts for wheelchairs, and bed and/or chair alarms were not used. She further stated if someone were to fall, she would let the nurse know immediately, document what happened, and make a falls report documenting what we saw and what we know. In interview with the 300-hall UM on 06/11/2025 at 10:45 AM, she stated she was familiar with R9, and thought his confusion was contributing to his falls. She stated he did not know what he was doing, and they had tried everything but restraints. The UM said she had talked to R9's wife and requested the wife hire a sitter to sit with the resident, or for family to come in and spend more time with him to try to help prevent falls. She stated the wife told her she came up here as much as she could. The UM explained R9's wife thanked them for doing everything they could for R9. She stated she thought R9 should be in a neurorestorative or brain injury center. In interview with PTA 2 on 06/11/2025 at 12:11 PM, she stated she had been working with R9, who was physically not bad and usually was very cooperative and very strong. She stated his strength was the problem because he was strong enough to move around by himself which had been leading to his falls. PTA 2 reported R9 was just so confused and had delusional conversations. She stated R9 overestimated himself and did not know where he was or what was going on, and did not remember when he fell. PTA 2 said the Pommel cushions (used to maintain proper hip and leg alignment) being used in some residents' wheelchairs were to prevent contractures and not used to prevent someone from falling out of a wheelchair. In interview on 06/11/2025 at 1:35 PM, the Director of Nursing (DON) stated she believed R9's behavior stemmed from his TBI. She said the facility had done everything to try to prevent R9's falls including: placing him on a perimeter defining mattress; moving his bed so he could see out into the hallway; keeping his bed low to the floor and placing a mat on the floor beside his bed; and placing his bed up against the wall. The DON reported R9 was very strong and very fast, and when he was up in his wheelchair, they kept him sitting beside the nurse's station. She stated they used non-skid socks for R9 when up; took the footrests off of his wheelchair to prevent him from tripping over them; and had him seen by psychiatry (psych) for medication adjustments and recommendations. The DON said they could have a resident on 1:1; however, that was not long-term and they had asked if the family could come more. She reported when R9 returned from the hospital the IDT team would have a meeting to talk about other options to protect him. In additional interview on 06/12/2025 at 8:49 AM, the 300-hall UM stated recommendation had been made that R9 needed a 24/7 (24 hours a day times 7 days a week) sitter after talking with the clinical team. She said with R9 having so many falls, they were struggling with what to do next for him. The UM reported R9 had been falling frequently, pulling his PEG tube out, and having behaviors. She stated she felt he needed 1:1 care to prevent further falls and to keep him from pulling his PEG tube. The UM explained since R9 returned from the hospital yesterday, he had a sitter, just for the transition from the hospital. She stated it was up to the clinical team on how long the transition period would be and that decision was based on the resident's behavior and adjustment after returning to the facility from the hospital. The UM said R9 had a sitter while he was in the hospital; however, the facility had not provided any 1:1 services before yesterday. She stated they had been trying to take him to activities to provide diversionary activities and said they knew R9 had owned a radio station, so he had an Alexa (virtual assistant speaker) in his room. The UM further stated to assist R9 with toileting to prevent falls the aides were rounding on him every 2 hours to encourage toileting. In interview with the Assistant Director of Nursing (ADON) on 06/12/2025 at 9:00 AM, she stated the facility traditionally did not provide 1:1 care services. She stated R9 only had a sitter right now to help him adjust during the transition from the hospital where he had 1:1 supervision. The ADON said she felt R9 needed 1:1 supervision due to what he had been through. She reported since the family was not able to get a 24/7 sitter for R9, it was the facility's responsibility to keep him safe. The ADON further stated they had not gotten a sitter for R9 yet because they were exhausting all other options. In an interview with the DON on 06/12/2025 at 11:11 AM, she stated that the recommendation to the family for hiring a 24/7 sitter was based on R9's behavior and pulling his PEG tube out. She stated that they started him on one-on-one supervision when he got back from the hospital to assist with his transition back to the facility from the hospital and he had a sitter while in the hospital. She stated that she feels like 6 falls and pulling his PEG tube out twice would not warrant a sitter. She stated that if the family cannot hire a sitter or be present more with the resident, then it is the responsibility of the facility to keep him safe. She stated that depending on his behaviors is how long he will be on one-to-one supervision. She stated that R9 is followed by a nurse practitioner, seen by neurology, and they have an in-house psychiatric nurse practitioner. She stated that they review his medication regimen more often than is required. In an interview on 06/12/2025 at 11:50 PM, the facility's Administrator stated that she did not know when the recommendation was made for a 24/7 sitter to R9's the family. She said staff had been trying to increase their supervision of R9 by keeping him up by the nurse's desk. The Administrator reported staff had been trained to guide and direct residents so they could be comfortable in the least restrictive manner. She explained she did not know what dictated having a 24/7 sitter. The Administrator stated it was always the facility's responsibility to keep residents safe. She said the facility usually did not accept residents who came from the hospital on 1:1 care; however, as R9 was already been our patient, 1:1 care was provided for him to transition from the hospital. The Administrator further stated her expectations was for staff to follow the resident's care plan interventions to assist in reducing the risk of fall and injury.

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation of the walk in coolers revealed multiple food items which had been opened and were unlabeled and undated. These failures had the potential to affect 85 of the facility's 86 residents who consumed food from the kitchen. The findings include: Review of the facility policy, Food Receiving and Storage, revised 10/2017, revealed foods were to be received and stored in a manner that complied with safe food handling practices. Further review revealed all food stored in the refrigerator or freezer was to be covered, labeled, and dated with a used by date. Review of a document provided by the facility titled, United States Department of Agricultural Food Safety and Inspection Services for Food Safety Information Basics for Handling Food Safely, revised 08/2013, revealed safe steps in food handling, cooking, and storage were essential to prevent food borne illness. Continued review revealed leftover food was to be used within four days. Observation with the Dietary Manager (DM), during initial tour of the kitchen on 08/13/2024 at 6:37 AM, revealed a tray that contained five servings of banana pudding and one plate of prepared salad not labeled or dated located in a reach in cooler. Continued kitchen observation revealed the following items located in the walk in cooler: an opened, undated bag of shredded cheese 1/4 full; a small container of sloppy joe mixture, 1/4 full, dated 08/08-08/12/2024; a small container of mandarin oranges, dated 08/10-08/12/2024; a small container of sliced apples dated 08/09/2024-08/11/2024; an opened package of delicatessen (deli) turkey not labeled or dated; a container of chopped garlic 1/4 full, not labeled or dated; a large opened container of cantaloupe, 1/2 full with an opened date of 08/05/2024; and a large container of honeydew melon, 1/2 full with an opened date of 08/05/2024. The DM stated products were good for 7 days after opening. In interview with the DM on 08/13/2024 at 6:37 AM, during the kitchen tour, he stated food products were good for seven days after being opened. The DM stated food items placed in the cooler or walk-ins were also good for seven days. He further stated he expected staff to label and date all items as required. During interview with the former Registered Dietitian (RD) on 08/15/2024 at 2:28 PM, she stated the expectation was for all dietary staff to label and date items when placed in the cooler or the walk-ins. She stated all staff in the kitchen were aware items were to be labeled and dated. The RD stated items were to be dated for three days out. She further stated serving outdated food items could contribute to food borne illness. In an interview with the Administrator on 08/16/2024 at 2:01 PM, she stated she expected dietary staff to follow facility policy and procedure related to labeling and dating of stored food.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 22 sampled residents (R)87 and R45. 1. During observation of provision of direct care for R87, the two nurse aides failed to follow the enhanced barrier precautions (EBP) for the resident who was on EBP related to having an indwelling Foley catheter. 2. During observation of meal service CNA 4 entered R45's room, without donning an N95 mask (disposable filtering facepiece respirator) when entering a known COVID positive resident's room that was designated to have Droplet Precautions. The findings include: Review of the facility policy titled, Enhanced Barrier Precautions (undated), revealed it was the intent of the policy to protect residents who were the most susceptible for infections. Continued review revealed the use of EBP triggered for any resident in the facility with an open wound, an indwelling device, or who was colonized with multi drug resistant organisms. Review of the medical record for R87 revealed the facility admitted the resident on 08/09/2024, with diagnoses that included: right middle cerebral artery cerebral infarction, Type 2 diabetes mellitus, and Atrial fibrillation. Resident #87 medical record reflected urinary retention requiring indwelling Foley catheter placement which required enhanced barrier precautions. EBP supplies are in place in the hallway outside of the room entry door of Resident #87. The hallway has the standard PPE setup in place with gowns and gloves. Review of R87's comprehensive care plan revealed the facility care planned the resident on 08/09/2024, for a problem for R87 being placed on EBP due to an indwelling Foley catheter. Continued review revealed the goal as R87's risk for infection to be managed through the next review date. Further review revealed the interventions included using a gown and gloves for high contact activities, such as transferring R87 and providing the resident's hygiene care. Observation on 08/15/2024 at 4:34 PM, of CNA 14 and CNA 15 providing incontinent care for R87, revealed the aides had not followed the EBP's for wearing a gown when providing incontinent care (a high contact activity) for the resident. In interview at the time of observation, Certified Nursing Assistant (CNA) 15 stated she had forgotten to wear a gown as R87 needed to be changed and the resident did not want to wait. In interview on 08/16/2024 at 10:22 AM with CNA 15 she stated she had seen R87's care plan in the Kardex during report and that information was also shared by the nursing staff as well. She stated a nurse reported to her that R87 had been placed on EBP, prior to the observation of care. The CNA stated she was provided in-service education when EBP began at the facility, and also had re-education yesterday (08/15/2024) and again today about the EBP process. CNA 15 stated, I should have worn a gown, closed the curtain, and washed my hands, which were the main things she should have done during R87's care. She stated she was aware if the resident's care plan and EBP guidelines were not followed, a spread of infection could take place for that resident. In interview 08/15/2024 at 11:34 AM, the Assistant Director of Nursing (ADON) stated she served as the facility's Infection Preventionist (IP). The ADON stated the facility had some problems in the beginning with EBP compliance by staff and getting them to understand what to do, but that had gotten better. In a follow up interview on 08/16/2024 at 10:15 AM, the ADON stated staff members involved in the care of R87 the day before, had both received initial EBP training when it was first launched at the facility. She stated both those staff members came forward yesterday to leadership and said they had made a mistake regarding EBP. Per the ADON's interview, the facility provided re-education of both staff members that day (08/16/2024). The ADON stated one of the nurse aides involved was a senior nurse aide and if she could forget to follow EBP, she (ADON) felt like the facility needed to reinforce the EBP education with everyone. She stated the Kardex care plan was available to the nurse aides to refer to and staff members not following a resident's EBP care plan, could potentially spread infection. 50153 2. Review of the policy titled, Isolation - Categories of Transmission-Based Precautions with a revision date of September 2022, revealed transmission-based precautions were initiated when a resident developed signs and symptoms of a transmissible infection. Continued review revealed transmission-based precautions were also initiated when a resident arrived for admission with symptoms of an infection, had a laboratory confirmed infection, or was at risk of transmitting infection to other residents. Per policy review, revealed transmission-based precautions were additional measures that protected other residents, staff, and visitor from being infected. Further review revealed the three types of transmission-based precautions were contact, droplet and airborne. In addition, review revealed for droplet precautions Masks are worn when entering the room. Record review for R45 revealed the facility admitted the resident on 04/01/2022, with diagnoses that included: Chronic Diastolic (Congestive) Heart Failure; Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Review of R45's Physician's orders revealed R45 was placed in droplet isolation precautions on 08/04/2024, related to COVID positive test result, every shift for 10 days. Review of R45's care plan revealed a focus area of COVID 19 Active infection: Risk for worsening respiratory symptoms related to positive COVID 19 test as of 08/04/2024 initiated on 08/04/2024. Per review, the interventions included droplet isolation precautions with appropriate personal protective equipment (PPE) in accordance with PPE optimization guidelines initiated on 08/04/2024. Further review revealed the interventions also included, Single room droplet isolation precautions. All care to be performed in room, with an initiation date of 08/08/2024. During observation of meal service on the Lower Town unit on 08/14/2024 at 12:43 PM, CNA 4 was observed to enter R45's room, without donning a N95 mask, who was to be on droplet precautions for being COVID positive. Continued observation revealed CNA 4 was wearing a gown, gloves, and a face shield that was tipped backward at the level of the nose, leaving the mouth exposed. Per observation, CNA 4 had no face mask observed in use. Further observation revealed Droplet Precautions signage posted and visible outside R45's room and PPE available outside the room that included gowns, gloves and N95 masks. In interview with CNA 4 on 08/14/2024 at 12:45 PM, she stated it was important to wear a mask, but there were no masks located in the PPE bin that was located outside of R45's room. The State Survey Agency (SSA) Surveyor observed the PPE container, located outside R45's room, with CNA 4 and N95 masks were visualized as accessible and available in the second drawer of the PPE container. In interview with LPN/UM 2 on 08/14/2024 at 12:43 PM, she validated CNA 4 had not been wearing a mask when inside R45's room, who was COVID positive and on droplet isolation precautions. LPN/UM 2 stated it was important for staff to wear an N95 mask in a room of a resident on droplet precautions for infection control purposes and for preventing spread of the infection. In interview on 08/16/2024 at 3:32 PM, the DON stated it was her expectation for staff to use PPE as indicated to prevent the spread of COVID infection.

Based on interview, record review and review of the facility's Medical Director's responsibilities, it was determined the Medical Director failed to resident care policies for behaviors were implemented and failed to coordinate the medical care within the facility for 1 of 22 sampled residents, (R)84. The facility admitted R84 to the facility on [DATE] and the level 1 Pre-Admission Screening and Resident Review (PASRR), indicated a level 2 was indicated. The level 2 PASRR indicated R84 MUST receive psychiatric (psych) services on a monthly basis. However, the facility's Medical Director was not aware of that information and therefore, failed to ensure the facility provided R84 with the recommended psych services. On [DATE] at 2:10 AM, R84 was found in her bed with oxygen tubing wrapped ,d+[DATE] times around her neck and was pronounced deceased at 2:43 AM. Review of R84's Certificate of Death dated [DATE], revealed the cause of death as Ligature Asphyxiation, rubber oxygen tubing used to intentionally obstruct airway, and the death was ruled a suicide. The findings include: Review of the facility policy titled, Medical Director dated ,d+[DATE], revealed the Medical Director was a licensed Physician in the State and was to be responsible for ensuring adequate and appropriate Physician services. Per review, the Medical Director's functions included: acting as a consultant to the Director of Nursing (DON) in matters relating to resident care services. Further review revealed the Medical Director was also to help assure residents received adequate services appropriate to meet their needs, and helping assure residents' care plans accurately reflected the medical regimen. Review of the facility's, Medical Director Service Agreement, signed by the Medical Director on [DATE], revealed the Medical Director agreed to coordinate medical care, participate in the development and updating of patient care policies, and was responsible for seeing the policies were executed. Continued review revealed the Medical Director was also responsible for the overall coordination of the medical care provided in the facility to ensure the adequacy and appropriateness of the medical services provided to patients. Further review revealed the Medical Director additionally shared responsibility for assuring the facility was providing appropriate care as required and was responsible for evaluating and taking appropriate steps to correct any possibility of inadequate medical care. Review of the closed record for R84 revealed the facility admitted the resident on [DATE], with diagnoses that included: major depressive disorder, recurrent, mild; schizoaffective disorder, bipolar type; and generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment for R84 dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Record review revealed the Medical Director had been R84's primary care Physician (PCP). Review of R84's Comprehensive Care plan dated [DATE], revealed the facility developed a care plan for Depression/Mood State related to depression, dysfunctional grieving, depression related to life changes, medical condition and psychiatric conditions. Per review, the facility also developed a care plan for Psychotic Disorder, altered thought process, related to bipolar effective disorder and schizoaffective disorder dated [DATE]. Continued review revealed the interventions for those care plans included: encouraging R84 to verbalize feelings and offer emotional support; and attempt to identify stressors contributing to R84's behaviors and remove them if possible. Further review revealed to administer R84's medication as ordered; provide a mental health consult when ordered; observe for signs and symptoms of change in her condition and notify the Physician as needed. Review of the records from an outside behavioral health services provider revealed R84 failed to keep her appointments on [DATE], [DATE], [DATE] and [DATE]. Continued review revealed the outside behavioral health services provider discharged R84 on [DATE], to adhere to her treatment plan by keeping her appointments. Review of the consent form dated [DATE], from the facility psychiatric (psych) services provider revealed the Social Services Director (SSD) documented R84 refused to be seen by the facility psych service group. However, further review revealed no documented evidence the outside behavioral health services provider was contacted for R84's treatment or of the Medical Director being notified of the resident's refusal of the facility's psych service provider. Review of the handwritten document titled, Nursing Facility Initial Visit, revealed the Medical Director saw R84 on [DATE]. Continued review revealed the Medical Director noted R84 had a past medical history of schizoaffective disorder, and anxiety. Further review revealed the Medical Director documented R84 had no apparent distress and under Assessment noted the resident's depression and schizoaffective disorders were stable. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84. Per review, the Medical Director noted R84's fatigue, depression, and anxiety were stable. Review further revealed the Medical Director documented R84's medications had been reviewed and the facility was to continue the same. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84. Further review revealed the Medical Director documented R84 continued to have fatigue, her depression was stable, and her medications were reviewed. Review of the Nursing Progress Note dated [DATE], documented by Registered Nurse (RN) 2 revealed she had witnessed R84 to occasionally have crying spells which she was going to report to social services. However, further review of R84's medical record revealed no documented evidence of RN following up with social services. Additional record review revealed R84 had been seen by the APRN on [DATE], related to having increased anxiety. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84. Review further revealed the Medical Director noted R84 was stable with her anxiety, and her medications were reviewed. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84 and her anxiety was stable. Review of the Nursing Progress Note dated [DATE] at 5:01 AM, documented by Registered Nurse (RN) 2 revealed the RN entered R84's room to obtain vital signs around 2:00 AM. Per review, upon entering the room RN 2 observed the resident lying on the bed with her oxygen tubing wrapped around her neck five to six times. Continued review revealed the RN called for assistance from Certified Nursing Assistants (CNAs) and two other nurses in the facility. Further review revealed Cardiopulmonary Resuscitation (CPR) was initiated by the charge nurse, RN 3. Additionally, review revealed Licensed Practical Nurse (LPN) 3 notified Emergency Medical Services (EMS) and CPR was continued until their arrival. EMS arrived and took over the CPR, and connected R84 to the defibrillator; however, the resident was asystole (no pulse). Review of the Death Certificate for R84, received from the County Coroner's office, dated [DATE], revealed the resident's presumed time of death was at 2:43 AM. Continued review revealed R84's manner of death was suicide with a history of depression. Additionally, review revealed R84's cause of death was noted to be Ligature Asphyxiation, using rubber oxygen tubing, to intentionally obstruct the airway. In an interview with the Coroner on [DATE] at 4:24 PM, she stated she responded to the facility's report of a suicide on [DATE]. She stated upon her arrival, R84 was deceased and she observed the resident to have four deep grooves in the neck from the oxygen tubing. The Coroner stated R84 also had discoloration around the neck, petechial hemorrhages to both eyes, a red face, and her chest area was blanched. She stated R84 had bleeding from the nose and both ears which was not uncommon. The Coroner stated there was no evidence to indicate R84 had made any adjustments to the tubing or attempted to self release the tubing. She further stated it would have taken only one to two minutes of hard pressure to the neck before the resident expired. Review of the facility's investigation revealed it included witness statements from staff that were working at the time of the incident. Per review, of the facility's interviews, located in the investigation, with RN 2, LPN 3, CNA 5 and CNA 6 revealed all staff reported they observed no changes in R84 on the night of the event. Continued review of the investigation revealed RN 2 said R84 had a scheduled appointment on [DATE] with a pulmonologist and seemed excited to be going out with her son for the appointment. Additionally, review revealed following the investigation it was determined R84 had self inflicted an injury which resulted in her death on [DATE]; however, there was no indication that staff could have predicted her actions. Review of the Ad Hoc Meeting documentation dated [DATE] at 1:56 PM, revealed the Medical Director was present via telephone call. Continued review revealed a discussion was held during the meeting regarding the recent event of a self-inflicted death (R84's) and the ongoing investigation related to the incident. In an interview with CNA 5 on [DATE] at 8:55 AM, she stated she had observed mood changes in R84 following phone calls with her spouse and/or children. The CNA stated sometimes R84 seemed different and distant and had told her (CNA 5) that her spouse had promised to come get her out of the facility and take her home. During an interview with CNA 6 on [DATE] at 9:08 AM, she stated she did not wish to discuss the event regarding R84's death. She stated it was devastating, the worst thing she had experienced as a CNA. CNA 6 did state however, she had not seen changes in R84 that day. In an interview with RN 2 on [DATE] at 9:52 AM, she stated she started working at the facility in September of 2022, as the night shift nurse on the 100 hall where R84 resided. She stated R84 had been cognitively intact and ambulated about ad lib. The RN said she had witnessed R84 to occasionally have crying spells. She stated on the night of the event, there had been no indications that R84 was depressed and the resident had discussed with her (RN 2) the upcoming appointment on [DATE], her son was taking her to. Per RN 2's interview, R84 returned to her room after getting tea from the kitchen. She stated at approximately 2:15 AM, when she (RN 2) entered the room to obtain the resident's vital signs, she saw R84 lying on the bed with her oxygen tubing looped around her neck four or five times. In an interview with the former Social Services Director (SSD) on [DATE] at 8:50 PM, she stated had been the facility's SSD from April, 2022 to April, 2023; however, she did not have a degree in social work. The former SSD stated she had been responsible for completion of the Patient Health Questionnaire (PHQ) 9 indicators for Depression Scale. Per the former SSD's interview, if a resident scored high on the PHQ 9 she referred them to psych services and to the Nurse Practitioner (NP) and DON. She said R84 had scored high on the PHQ 9 that had been completed, but she was unable to recall the date it was performed. The SSD stated she informed the DON of R84's high PHQ 9 score. The former SSD stated she referred R84 to the facility's psych services; however, the resident did not want to see that psych services. She said she did not attempt to refer R84 to an alternative psych provider for psych services. The former SSD stated she did not recall R84 having any kind of telehealth visits, including psych, scheduled through the facility and she never attempted to offer the resident further psych services. In interview with the former DON on [DATE] at 9:30 AM, she stated she received a call from LPN 3 stating R84 had wrapped her oxygen tubing around her neck and was deceased . She stated she called the Administrator and headed to the facility where the Coroner and law enforcement were upon her arrival. In additional interview on [DATE] at 12:11 PM, with the former DON, she stated on admission to the facility R84 had declined receiving psych services from the facility. Per the former DON, R84 told staff she would continue with a different provider as she was familiar with them. She stated R84 was her own person, made her own appointments and had her own transportation. The former DON stated she was not aware until R84 died that she had not been receiving services from her preferred psych provider. She further stated R84 had a toxic relationship with her spouse who she went out of the facility with often. The former DON also stated R84 and her spouse would sometimes argue on the phone and after that the resident sometimes seemed sad. During an interview with the Medical Director on [DATE] at 12:11 PM, he stated R84 had been a new patient to him when she was admitted to the facility. The Medical Director stated he had not been aware of R84's mental health history until he reviewed her chart after admission. He stated he had been R84's PCP; however, did not recall being informed of R84 missing her scheduled mental health appointments and but stated, sometimes things got missed. Per the Medical Director's interview, he had not been aware of R84 interactions with her spouse that affected her mood. He stated he did not think her medications would contribute to suicidal ideations. He stated the death of R84 was gut wrenching and devastating. The Medical Director stated the facility held a Quality Assurance Performance Improvement (QAPI) meeting following the event involving R84 which he attended. In interview on [DATE] at 2:01 PM, the Administrator stated her knowledge of R84 was that the resident had been a nurse at one time and had experienced a hard home life with her spouse. She stated she was not aware of R84's mental health history until her death on [DATE]. The Administrator stated she did not recall any concerns with psych issues related to R84. She stated she not sure of how communication should have happened between the resident, the preferred psych provider and the facility in regards to the mental health appointments Resident 84 had and did not go to. The Administrator stated she would have had expected the mental health provider however, to communicate with the facility when appointments were scheduled for R84 or when the resident failed to show for those appointments. She stated she also would have expected the mental health provider to communicate with the facility when they discharged R84 from their services. The Administrator stated she did not recall receiving any documentation from the resident's preferred (psych) provider however. Per the Administrator's interview, the SSD might have set up appointments for telehealth psych visits, but the nursing department should have been made aware of such appointments. She stated when residents exhibited threats of self harm or indicated any signs/symptoms of self harm that was a significant change. The Administrator said if that occurred the facility would initiate one to one supervision of the resident and proceed with transfer of the resident to a behavioral health unit or to the emergency room (ER) for evaluation. She stated she did not feel R84 had experienced a significant change prior to her suicide. The Administrator stated when the social worker completed the PHQ 9 indicator for depression scale and it was high she expected the social worker to notify the DON and/or the Physician or NP of the results, so it could be discussed with the clinical team.

Based on interview, record review and review of facility policy, the facility failed to provide and ensure Resident (R) 84 received necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R84's level 1 Pre-Admission Screening and Resident Review (PASRR) indicated a level 2 PASRR was needed. The level 2 PASRR indicated R84 MUST receive psychiatric (psych) services on a monthly basis. However, the facility failed to ensure R84 received the required monthly psych services. Therefore, on [DATE] at 2:10 AM, R84 was found lying on her bed with oxygen tubing wrapped ,d+[DATE] times around her neck, and was pronounced deceased . Review of the death certificate dated [DATE], revealed R84's cause of death was noted as Ligature Asphyxiation, rubber oxygen tubing used to intentionally obstruct airway, and the death was ruled a suicide. The findings include: Review of the facility policy titled, Behavioral Assessment, Intervention, and Monitoring, dated ,d+[DATE], revealed residents were to receive and the facility was to provide behavioral health services as needed to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Continued review revealed provision of behavioral health services were to be provided in accordance with the resident's comprehensive assessment and plan of care. Review revealed behavioral health services were to be provided by qualified staff who had the competencies and skills necessary to provide appropriate services to the residents. Continued review of the policy Behavioral Assessment, Intervention, and Monitoring dated ,d+[DATE], revealed under the assessment section all residents were to receive a Level 1 PASRR screening prior to admission. Per review, if the level 1 PASRR indicated an individual might meet the criteria for a mental disorder, intellectual disability, or related condition, he or she was to be referred to the State PASRR representative for the level 2 PASRR screening process. Review revealed the level 2 PASRR evaluation was to be used when conducting the resident's assessment and development of the care plan. Additional review of the Behavioral Assessment, Intervention, and Monitoring, dated ,d+[DATE], revealed under the management section, the (facility's) Interdisciplinary Team (IDT) was to evaluate residents' behavioral symptoms to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Per policy review, under the monitoring section, if a resident was being treated for altered behavior or mood, the IDT team was to seek and document any improvements or worsening in the individual's behavior, mood, and function. Further policy review revealed the IDT team was to monitor the resident's progress .until stable, with interventions adjusted based on the impact on behavior and other systems symptoms. Review of R84's closed record, Resident Face Sheet, revealed the facility admitted the resident on [DATE] with diagnoses to include; schizoaffective disorder, bipolar type, generalized anxiety disorder and major depressive disorder, recurrent, mild. Review of the facility's Admission Minimum Data Set (MDS) Assessment for R84 dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Continued MDS review of section D for mood, revealed a score of 21, which indicated R84 had been assessed as being severely depressed. Review of the Quarterly MDS assessment dated [DATE], of section D for mood, revealed a score of 10, which indicated R84 was assessed as being moderately depressed. Review of R84's Comprehensive Care plan dated [DATE], revealed the facility developed a focus problem for Depression/Mood State related to dysfunctional grieving, depression related to life changes, medical conditions, and psychiatric conditions. Review revealed the goal for R84 was management of her depression symptoms at an acceptable level to her through the next review date with a revision date of [DATE]. Review further revealed the interventions included encouraging R84 to verbalize feelings and offer emotional support. Continued review of R84's Comprehensive Care Plan revealed the facility also developed a Psychotic Disorder, altered thought process, related to bipolar effective disorder and schizoaffective disorder dated [DATE]. Review revealed the goal was to manage R84's symptoms of altered thought process through the next review date, revised on [DATE]. Per review , the interventions included: attempting to identify stressors contributing to R84's behaviors and removing them if possible; administering her medication as ordered; and providing a mental health consult when ordered. Further review revealed the interventions additionally included: observing for signs and symptoms of change in R84's condition and notifying the Physician as needed, and providing emotional support and reassurance. Review of the hospital record information dated [DATE], prior to R84's admission to the facility, revealed, the patient had a historical note of illicit drug use and advanced depression. Continued review revealed following medical stabilization, the intent was for R84 to transition to a facility; however, underlining suicidal gestures and actual indigestion of a foreign body (wedding rings). Per review, R84 was to be transitioned to the mental health unit for ongoing medical management and interventions. Further review revealed diagnoses for R84 included a history of Post Traumatic Stress Disorder (PTSD), psychosis, anxiety disorder, major depressive disorder, recurrent and bipolar disorder. Review of the Nursing Facility PASRR level 1 dated [DATE], under section 6 revealed the nursing facility staff were to refer the applicant to the Community Mental Health Center for completion of a Level 2 PASRR. Review of the PASRR, Level 2, Comprehensive Evaluation for Serious Mental Illness and Intellectual Disability/Related Conditions, dated [DATE], revealed the evaluation had been completed online. Per review, the PASRR representative had attempted to contact the facility for additional information on [DATE] at 10:25 AM, and 3:45 PM, on [DATE] at 8:15 AM, and on [DATE] at 10:00 AM, with no success, and no way to leave a voicemail. Continued review revealed under Section 8, determination revealed R84 met criteria for serious mental illness; however, did not require specialized services and the resident's total care needs could be met in the nursing facility. Review of a document titled, Notification of Recommended Services, for R84, and for the nursing facility, revealed the PASRR professional recommended completing the evaluation, and the resident had mental illness. Continued review revealed the recommended services to best meet R84's individual needs MUST be part of the care plan to ensure continuity of care and stabilization of depressive symptoms. Further review revealed R84 was to receive individual behavior or mental health services therapy on a monthly basis. Review of the physician order dated [DATE], revealed an order for R84's consults included consults as needed for neuro-psych, psychiatric and treatment as needed for the resident's health and comfort. Review of records from an outside psychiatric (psych) provider dated ,d+[DATE] through [DATE], revealed R84 failed to keep the following appointments on: [DATE], [DATE], [DATE] and [DATE] and on [DATE]. Continued review revealed R84 was discharged from the outside provider's services for failure to adhere to her treatment plan and no call no show for appointments. Further review of revealed the last psych treatment scheduled for R84 was on [DATE]. Review of the consent form for the facility's psych services provider revealed that on [DATE], the Social Services Director (SSD) documented R84, had refused to be seen by the facility's psych service group. However, further review of the form revealed no documented evidence the document had been signed by R84. Review of the Progress Note dated [DATE] at 10:47 AM, revealed, R84 had been sitting on the side of her bed sobbing. Continued review of the Note revealed the nurse asked R84 if she needed someone to talk to, and the nurse also told the resident the facility had a Social Worker or the nurse would listen to the resident. Further review revealed R84 stated as sobbing heavily, I will be alright I need no one at this time to tell my business to. Additional review revealed no documented evidence the nurse attempted to further address R84's behaviors, nor contacted the medical provider or psych services provider for additional interventions. Review of the Behavior Note dated [DATE] at 12:23 AM, revealed R84 had been crying and was visibly upset while talking on the phone with her husband. Per review, the Registered Nurse (RN) and aides provided emotional support for the resident, with PRN (as necessary) medications (meds) for anxiety given and documented. Further review revealed R84's behavior/emotional status observed by the nurse had been reported to the supervising nurse. Additional review revealed however, no documented evidence the supervising nurse addressed R84's emotional stated, nor notified the medical or psych provider of the resident's behaviors. Review of a Behavior Note dated [DATE] at 5:46 AM, revealed R84 had been up most of the night, silently crying. Per review, when the nurse asked R84 what was the matter, the resident just said, I am just thinking about life. Continued review revealed R84's scheduled Alprazolam (generic for Xanax, an anti-anxiety medication) given. Further review revealed the nurse would report R84 to social services and the clinical director for her behavioral concern. Additionally, review revealed R84 calmed down and slept soundly from 3:00 AM to 6:00 AM. Review of the Health Note dated [DATE] at 9:27 AM, documented by a Licensed Practical Nurse (LPN), revealed R84 had increased tearfulness this shift. Continued review revealed LPN sat with R84 to tried to comfort her and let her know we were here if she needed someone to talk to. Further review revealed the information regarding R84 was placed in the Advanced Practice Registered Nurse (APRN) book so the APRN could assess the resident when doing rounds tomorrow. Review of a Progress Note, documented by the APRN on [DATE], revealed she assessed R84 who had increased anxiety. Continued review revealed per nursing staff R84 had been more tearful and anxious at times recently. Further review revealed the patient reported she had just recently found out that she would be moving out of the nursing facility and was anxious about the upcoming changes and about living by herself. Review of the Behavior Note dated [DATE] at 4:15 PM, revealed, R84 came to the nurse and stated, I think I'm having a manic episode. Per review, R84 told the nurse, I'm going crazy. Continued review revealed the nurse noted having previously given R84 a PRN (as needed) Benadryl related to itching. Further review revealed the nurse contacted the Nurse Practitioner (NP) with no new orders received at that time. In addition, review revealed the nurse informed R84 she was due for her scheduled 6:00 PM Xanax soon, and the resident verbalized understanding and went back to her room. Review of the Progress Note dated [DATE] at 5:45 PM, revealed R84 came to the nurse's station requesting more nerve medication, stating her nerves were really bothering her. Review revealed the NP was notified and the nurse was given a one-time only order for Vistaril (antihistamine also used to treat anxiety) 50 milligrams (mg) by mouth. Continued review revealed R84 expressed she was not happy with that medication, and stated, This isn't going to do anything, I need something to knock me out. Further review revealed R84 ended up taking the (Vistaril) medication, and the nurse told the resident to wait for medicine the to kick in and see how she felt when it did. Review of the Progress Note dated [DATE] at 7:57 PM, revealed a one-time physician's order for an extra dose of Xanax 1 mg related to the resident's anxiety. Further review revealed R84 stated, I'm crawling out of my skin. Review of the Progress Note dated [DATE] at 8:45 PM, revealed R84 was standing at the nurses' station calm and stating, I've got to have something. Per review, the nurse informed R84 she could not have her pain meds until 9:30 PM, with the resident stating, I'm on edge. Continued review revealed the nurse informed R84 she just had Xanax and the only other thing we can do was to send her to hospital. Review further revealed R84 stated, I don't want to go to the hospital, and then returned to her room at that time. Review of the Progress Note dated [DATE] at 5:01 AM, revealed at approximately 2:10 AM, R84 was found lying on her bed with oxygen tubing wrapped four to five times around her neck. Review of the Kentucky Certificate of Death for R84 dated [DATE], revealed it listed the cause of the resident's death as Ligature Asphyxiation, rubber oxygen tubing used to intentionally obstruct airway. Further review revealed R84's death was ruled a suicide. In interview On [DATE] at 8:55 AM, Certified Nursing Assistant (CNA) 5 stated she had worked the night R84 passed away. Per CNA 5's interview, she and CNA 6 had been sitting at the nurse's station that night and R84 was walking down the hall and said, Hi girls, as she headed to the kitchen to get some tea. She stated she saw R84 go back to her room and there were no indicators the resident was in any distress or was in a bad mood. The CNA stated she had seen R84 have mood changes before after phone calls with her spouse. She stated R84 sometimes also seemed different and distant. CNA 5 further stated R84 told her (CNA 5) that her spouse had promised to come get her out of the facility and take her home. In interview on [DATE] at 9:08 AM, CNA 6 stated she had not seen changes in R84 the night of the event. In interview on [DATE] at 9:52 AM, Registered Nurse (RN) 2 stated she had been working at the facility since September of 2022, as the night shift nurse. She stated R84 had been cognitively intact and able to ambulate independently. RN 2 said she witnessed R84 occasionally having crying spells but on the night of the event, there had been no indications she was depressed. She stated that night R84 discussed her upcoming appointment to be cleared for cataract surgery and said she was pleased her son was coming to take her to that appointment. The RN stated R84 had been up around 12:30 AM to go get tea from the kitchen and had greeted staff sitting at the nurse's station on her way to the kitchen. She stated R84 returned to her room after getting the tea. RN 2 stated at approximately 2:10 AM, when she entered R84's room to obtain her vital signs she found the resident lying on the bed with her oxygen tubing looped around her neck five or six times. She additionally stated she assessed R84 and found no pulse, so she yelled for help and initiated cardiopulmonary resuscitation (CPR). In an interview with the facility's former Social Services Director (SSD) 1 on [DATE] at 8:50 PM, she stated she did not have a degree in social work; however, had been in the position of SSD from April of 2022 to April of 2023. Former SSD 1 stated she received no training for her role as SSD. She stated the facility had limited resources and the Social Services Assistant (SSA) was a former Certified Nursing Assistant (CNA). Per former SSD 1's interview, she had not been working at the facility when R84 was admitted and had no knowledge of the resident's history. The former SSD stated she thought she should have been informed of R84's psych history. She stated she was not aware R84 was supposed to have been receiving mental health services monthly and was not aware of R84 had seen an outside provider. Former SSD 1 stated that she had been responsible for completion of the Patient Health Questionnaire (PHQ) 9 indicators for the Depression Scale. She said if a resident scored high on the PHQ 9 she referred the resident to psych services, and the NP and Director of Nursing (DON) and that was all she knew who to report to. The former SSD stated she could not recall the date she completed the PHQ 9 for R84; however, the resident had scored high, so she referred her to the facility's psych provider, which she refused. The former SSD further stated she could not recall if she had documented the discussion but she did document it on the resident's consent form. During an telephonic (phone) interview with the facility's former SSD 2 on [DATE] at 9:52 AM, she stated she had a bachelors degree in human services and had left employment at the facility in [DATE]. She stated she did not do anything with the PASRR's and the Business Office Manager (BOM) completed a resident's PASRR on admission and notified her of the results. Former SSD 2 stated she was not aware of the results of R84's level 2 PASRR or of any recommendations made. She stated she had no knowledge of R84 seeing an outside psych provider for mental health services. Former SSD 2 also stated she was not made aware of most of the clinical things that occurred in the facility. During an interview with the former DON on [DATE] at 12:11 PM, she stated on admission to the facility R84 had declined psych services from the facility's psych provider. The DON stated R84 reported she would continue with the outside provider she was familiar with. She stated she was unsure if that had been documented in the resident's medical record though. The former DON stated R84 had been her own person, and had made her own appointments and arranged for her own transportation. She stated the facility should have been monitoring R84's behaviors or for changes on the medication administration record (MAR); however, that had not occurred. The former DON stated R84 had been a private person who kept to herself, and she did not know if they would have seen/observed anything different with the resident. During an interview with the Medical Director on [DATE] at 12:11 PM, he stated R84 had been a new patient to him when she was admitted to the facility. The Medical Director stated he had not been aware of R84's mental health history until he reviewed her chart following her admission. He stated he did not recall being informed of R84 missing her scheduled mental health appointments or of her not receiving mental health services until after her death. The Medical Director stated it did happen sometimes that he was not made aware of changes in residents. The Medical Director further stated he was not aware of R84 interactions with her spouse that affected her mood and did not see that as a problem. He additionally stated he did not think R84's medications would have contributed to her having suicidal ideations. During an interview with the Administrator on [DATE] at 2:01 PM, she stated that she had been the facility's Administrator for about two and a half years. She stated her knowledge of R84 included the resident having been a nurse at one time and that she had experienced a hard home life with her spouse. The Administrator stated she had not been aware R84 had a history of mental health issues until her death on [DATE]. She stated R84 had been her own person, made her own decisions and had a BIMS score of 15, indicating she was cognitively intact. The Administrator said she did not recall any concerns with psych issues for R84 and had never met the resident's spouse. She stated she was unsure of how communication should have occurred between the outside psych provider and the facility in regards to the mental health appointments that R84 had attended with them. The Administrator further stated she did not recall receiving any documentation from the preferred provider about appointments or of them discharging R84 from their services. In continued interview on [DATE] at 2:01 PM, the Administrator stated the SSD might have set up appointments for psych telehealth for R84; however, nursing should have been made aware of that information. She stated when residents made threats of self harm or indicated signs and symptoms of self harm, that would be a significant change for a resident. The Administrator additionally stated the facility would initiate 1:1 supervision for residents with that behavior, and proceed with transfer to a behavioral health unit or to the emergency room (ER) for evaluation.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). Review of a facility Fall Scene Investigation Reports, dated 02/15/2021 and 02/21/2021, revealed Resident #1 had falls from the bed and sustained fractures on 02/15/2021 and again on 02/21/2021. Interventions put in place after the resident's first fall, in which he/she fell while reaching for the call light on 02/15/2021 at 11:30 PM, was to keep the bed in low position and to clip the call light to the resident. The second fall on 02/21/2021 at 3:50 PM, the resident was trying to reach his/her call light, interventions put in place were to remind the resident his/her call light was attached to his/her gown. However, further review of of the Fall Scene Investigation Reports, revealed the interventions for a low bed and to keep the resident's items/call light within reach were not implemented. Review of the emergency room record, dated 02/21/2021, revealed Resident #1 sustained a right nasal bone fracture. The facility's failure to ensure each resident's person centered comprehensive care plan interventions were implemented to meet the resident's needs has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/12/2021, and was determined to exist on 02/15/2021 at 42 CFR 483.21 Resident Assessments (F656) and CFR 483.25 Quality of Care (F689). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 07/12/2021. An acceptable Allegation of Compliance (AoC) was received on 07/13/2021. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 07/14/2021. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive, person centered care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and would be developed and implemented for each resident. Further review of the policy revealed the care plan would incorporate identified problem areas. Record review revealed the facility admitted Resident #1 on 01/26/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated cognitive impairment. The MDS also revealed the resident required the assistance of two (2) staff for bed mobility, transfers, dressing and toilet use. In addition, further review of the MDS revealed the resident's balance during transitions was not steady, he/she was only able to stabilize with staff assistance. Review of a facility Fall Scene Investigation Report dated 02/15/2021 and 02/21/2021, revealed Resident #1 had fallen from the bed. Further review revealed the facility determined the cause of the falls was the resident's call light was not within reach. Review of a facility Fall Scene Investigation Report, dated 02/15/2021 at 11:30 PM, revealed State Registered Nurse Aide (SRNA) #13, found the resident on the floor near his/her bed and the resident had stated My call light was on the floor and I was trying to reach it. The facility determined the cause of the fall was the resident's call light was not within his/her reach. Further review of the report revealed added interventions included keeping the residents bed in low position and the call light clipped to the resident. Review of a facility Fall Scene Investigation Report, dated 02/21/2021 at 3:50 PM, revealed staff found the resident lying on his/her back, on the floor, door side of the room, near his/her bed. The resident had stated he/she was reaching for the call light and fell out of bed. Further review of the report revealed added interventions included reminding the resident to look for call light attached to his/her gown. Review of a facility Fall Scene Investigation Reports, dated 02/15/2021 and 02/21/2021, revealed Resident #1 had falls from the bed and sustained fractures on 02/15/2021 and again on 02/21/2021. Interventions put in place after the resident's first fall, in which he/she fell while reaching for the call light on 02/15/2021 at 11:30 PM, was to keep the bed in low position and to clip the call light to the resident. The second fall on 02/21/2021 at 3:50 PM, the resident was trying to reach his/her call light, interventions put in place were to remind the resident his/her call light was attached to his/her gown. However, further review of of the Fall Scene Investigation Reports, revealed the interventions for a low bed and to keep the resident's items/call light within reach were not implemented. Review of a Nursing Progress Note dated 02/19/2021 at 2:04 PM, revealed LPN # 2 was called to Resident #1's room on 02/15/2021 where he/she was noted on the floor. Resident #1 was laying on his/her back with their feet straight out in front of him/her, under the bed. Resident #1 was bleeding from the right wrist. Resident #1 revealed he/she did not hit his/her head and he/she was reaching for the call light when he/she fell out of the bed. Review of Resident #1's Comprehensive Care Plan dated 02/04/2021, revealed the facility initiated fall interventions that included, encourage rest periods as needed to avoid over-tiring, encourage to wear non-skid footwear as much as resident chooses to comply, frequently used items within reach, observe for acute process - notify MD, therapy screens PRN (as needed) and verbal reminders not to attempt independent transfers. Review of emergency room record, dated 02/18/2021, revealed Resident #1 sustained a left humeral head fracture, fracture of [MEDICATION(S)] vertebra 12, Lumbar 4 and 5 vertebra. Review of the emergency room record, dated 02/21/2021, revealed Resident #1 sustained a right nasal bone fracture. Interview with Family Member #1, on 06/01/2021 at 7:22 PM, revealed during a care plan conference on 02/02/2021, therapy and nursing staff recommended the resident not be left alone and advised that he/she needed twenty-four hour care. The family member further revealed the facility had not put interventions in place before or after the resident's fall on 02/15/2021. Family Member #1 stated he/she had asked the resident why he/she fell and the resident stated staff told the resident he/she used the call light too much and took the call light away. Family Member #1 further revealed he/she had not seen the resident on a low bed during window visits and the Director of Nursing (DON) stated the resident may have fallen because he/she was in a smaller bed. Interview with State Registered Nurse Aide, (SRNA) #2, on 06/03/2021 at 4:50 PM, revealed on 02/15/2021, he and another SRNA were providing care for another resident when Resident #1's call light went off. He stated when he arrived the resident was on the floor near the recliner and his/her call light was on the floor. SRNA #2 further stated the resident was crying and had a skin tear to his/her right hand and they called for a nurse. He stated the nurse assessed the resident and assisted him/her back to bed. He further revealed he was not aware of fall interventions that were in place before or after the fall. Interview with SRNA #13, on 07/12/2021 at 1:22 PM, revealed on 02/15/2021, she was walking by Resident #1's room and noticed the resident was not in the bed. SRNA #13 stated she found the resident lying on the floor and the resident stated, I was trying to get my call light it was on the floor. SRNA #13 stated she could not recall any fall interventions for the resident. She further stated the Kardex (SRNA plan of care) located on the Kiosk, list the resident's falls interventions. SRNA #13 revealed she had put the bed in low position following the fall. Interview with Licensed Practical Nurse (LPN) #2, on 06/07/2021 at 4:30 PM, revealed he was the nurse when Resident #1 fell from the bed on 02/15/2021. He stated he was not aware of any preventative interventions in place prior to the fall on 02/15/2021. LPN #2 revealed after the resident fell on [DATE], he updated the resident's care plan in Point Click Care (PCC) to include the bed be in low position and to frequently check placement of call light. Interview with LPN #3, on 06/07/2021 at 4:21 PM, revealed on 02/21/2021, SRNA #7 reported to her the resident had fallen out of the bed. LPN #3 stated the resident had a nose bleed, but did not want to go to the hospital. She further stated she called the Advanced Practice Registered Nurse (APRN) and Emergency Medical Services (EMS) and made the resident comfortable on the floor until EMS arrived. LPN #3 further stated she thought there was a perimeter defined mattress on the resident's bed, but the resident was not on a low bed. Interview with SRNA #7, on 06/07/2021 at 4:05 PM, revealed on 02/21/2021, she was returning from break and noticed the resident's call light was on and went to answer it. She stated the resident was on the floor beside the bed with the call light call in his/her hand and noticed the call light had been pulled from the wall. SRNA #7 stated the resident was laying on his/her back on the right side of the bed. She revealed the resident was not moved until the ambulance arrived. SRNA #7 further revealed the resident was crying and upset. SRNA #7 revealed the resident was in bed prior to the fall and the resident's bed was not in low position at the time of the fall. Interview with Registered Nurse (RN) #2, on 06/01/2021 at 2:35 PM, revealed the Director of Nursing (DON) had placed a Perimeter Defined Mattress on Resident #1's bed on 02/16/2021 but she was not aware of any other interventions put in place. Interview with Clinical Director #14, on 06/04/2021 at 9:34 AM, revealed she expected interventions to be added to the care plan at the time a fall occurred. She revealed the IDT reviewed all falls the next day to ensure everything had been done. Interview with Minimum Data Set (MDS) Coordinator, on 07/12/2021 at 11:23 AM, revealed the admitting nurses were responsible for initiating the baseline care plan in PCC. She stated she was responsible for the completion of the comprehensive care plan. The MDS Coordinator further revealed the clinical directors do help with the care plans, if a resident had fallen because their responsibility includes updating the care plan with new interventions in PCC at that time. She further stated the clinical directors review falls in the clinical meeting each day, to make sure the nurse updated the care plan with the new intervention. Interview with Assistant Director of Nursing (ADON), on 07/12/2021 at 3:22 PM, revealed the admitting nurse should initiate the resident's baseline care plan. She stated the nurses and clinical directors continue updating the care plan until the MDS nurse does the comprehensive care plan. The SRNA's utilize the Kardex because it lets them know what interventions should be in place. They may also be told in report. The ADON further revealed the care plan were used as a guide to staff on how to care for a resident. She stated if the care plans were not updated, the care plans could be very misleading. Interview with Director of Nursing (DON), on 06/08/2021 at 12:20 PM, revealed she expected the nursing staff to ensure care plan interventions were implemented while caring for residents. She further revealed the care plans were to be updated with new interventions if a resident had a fall. **The facility implemented the following actions to remove Immediate Jeopardy: 1). The ADON, Clinical Director, Clinical Nurse Consultant, Infection Preventionist, Admissions Nurse, and MDS Nurse reviewed all current residents' Fall Risk Evaluations on 07/12/2021, to ensure they accurately reflected the residents status. 2). The Clinical Nurse Consultant, ADON, MDS, Infection Preventionist, and Admission Nurse, completed a 100% audit of all care plans of resident's with high risk for falls to confirm adequate supervision, appropriateness of interventions, and assistive devices were in place as needed on 07/12/2021. 3). The incident investigations for current residents who experienced falls in the prior 60 days, were audited to verify that appropriate interventions were implemented based on the investigation findings. This audit was completed by Clinical Nurse Consultant by 07/01/2021. Any needed changes to interventions or care plans were revised at that time. 4). All assistive devices in place as fall interventions, including but not limited to beds in low position, were inspected to verify placement and function by Clinical Nurse Consultant on 07/13/2021. . 5). All call lights were inspected to verify they functioned and alarmed as designed by Maintenance Director on 07/13/2021. 6), Education and in-service training were provided to nursing staff on areas for opportunity to include topics of: requirement to refer to the care plan/Kardex for planned interventions, updating and revision of care plans, the need to conduct thorough investigation of incidents to establish root cause, and initiate a new intervention to address causative or contributing factors following an incident or accident. The education was provided by DON, ADON, SDC, or Clinical Nurse Consultants on 06/15/2021, 06/16/2021, 06/17/2021 and 06/18/2021. The Clinical Directors (CD), Assistant Director of Nursing (ADON) and Director of Nursing (DON) were educated regarding review of incident investigations for completion and to validate that the intervention was appropriate for the root cause, had been added to the care plan, and was implemented. This education was provided on 06/14/2021 by the Clinical Nurse Consultant. Any staff that had not completed education by 06/18/2021 was not permitted to work until training was completed. 7). Post tests were administered on the above topics by the DON, ADON, SDC, and Clinical Directors, and Clinical Nurse Consultants beginning on 06/15/2021 with 100% score attained. 8). The facility would also implement monitoring measures and random audits spread over the course of the next 90 days to ensure compliance and efficacy of this plan. Any negative areas identified during audits will be immediately corrected at that time. 9). All audit results would be shared with the facility Quality Assurance Performance Improvement (QAPI) team and the Medical Director no less than monthly for review. All negative audit results will be immediately brought before the QAPI team and Medical Director for immediate review and remedy. 10). On 06/15/2021, the Administrator and DON gathered the facility's policies and procedures regarding development and implementation of person-centered care plans and began 100% in-servicing of all nursing staff on this topic. Continuing sessions of the education were provided by trained department managers as well as Administrative Nursing Leaders, Staff Development Coordinator, and Clinical Nurse Consultants on 06/15/2021, 06/ 1, 06/17/2021, and 06/18/2021. Post test administered upon completion of this training with scores of 100% attained. Starting on 06/18/2021, no clinical staff will be permitted to work until education and post-test have been completed. These topics were added to clinical new hire orientation effective 07/13/2021. Compliance would be ensured and tracked by each employee's respective department manager. 11). On 07/13/2021, available QAPI team members met with Medical Director (proxy) via telephone to initiate Root Cause Analysis and to implement a QAPI Action Plan. The plan was reviewed and revised by the complete Inter Disciplinary Team and by the Medical Director (proxy) on 07/13/2021. The Inter Disciplinary Team and Medical Director will attend QAPI meeting to review the efficacy of the aforementioned plan weekly x 4 weeks, then bi-weekly x 1 month, then monthly thereafter to ensure continued compliance with the requirements of participation. The IDT included the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admissions Coordinator, Staff Development Coordinator, Housekeeping Director, Maintenance Director, MDS Nurse, Dietary Director, and Medical Director. ** The State agency verified the facility's corrective action as follows, and determined the facility removed the immediate jeopardy on 07/14/2021 as alleged. 1). Review of all current residents' Fall Risk Evaluations dated 07/12/2021, revealed they were reviewed by the ADON, Clinical Director, Clinical Nurse Consultant, Infection Preventionist, Admissions Nurse, and MDS Nurse Interviews with the MDS Nurse, on 07/12/2021 at 11:23 AM and the ADON on 07/12/2021 at 3:22 PM, verified they had reviewed all current resident's Fall Risk Evaluations the for all residents. 2). Review of care plans of current residents identified at high risk for falls, revealed the Clinical Nurse Consultant, ADON, MDS, Infection Preventionist, and Admission Nurse, completed audits of all care plans of current residents with high risk of falls to ensure accuracy of the fall interventions on 07/12/2021. 3). Review of incident investigations for current residents who experienced falls in the prior 60 days, revealed the Clinical Nurse Consultant completed audits by 07/01/2021, to verify appropriate interventions were implemented based on the investigation findings. 4). Review of a audit tool of interventions, dated 07/13/2021, revealed all assistive devices in place as fall interventions, including but not limited to beds in low position, were inspected to verify placement and function by the Clinical Nurse Consultant. Interview with the Clinical Nurse Consultant, on 07/19/2021 at 4:02 PM, verified she had inspected all assistive devices in place as fall interventions, to check placement and function. 5). Review of a call light audit tool, dated 07/13/2021, revealed the Maintenance Director had inspected all call lights to verify they were functioning and alarmed as designed. 6). Review of the education rosters, dated 06/15/2021 through 08/18/2021, revealed the DON, ADON, SDC, or Clinical Nurse Consultants educated nursing staff on areas for opportunity to include topics of: requirement to refer to the care plan/Kardex for planned interventions, updating and revision of care plans, the need to conduct thorough investigation of incidents to establish root cause, and initiate a new intervention to address causative or contributing factors following an incident or accident. Review of the education roster, dated 06/14/2021, revealed the Clinical Nurse Consultant educated the Clinical Directors, ADON, and DON, regarding review of incident investigations for completion and to validate the intervention were appropriate for the root cause, had been added to the care plan, and were implemented. Interviews on 07/19/2021 at 3:15 PM with the ADON and at 1:56 PM, with the Clinical Director, revealed they received education from the Clinical Nurse Consultant on incident investigations for completion, validating the intervention were appropriate for the root cause, had been added to the care plan, and were implemented. Interviews on 07/19/2021 at 1:40 PM, with LPN #5, 8:51 AM, with LPN #6, and 9:01 AM, with LPN #1, revealed they received education from the DON, ADON, SDC, or Clinical Nurse Consultants on areas for opportunity to include topics of: requirement to refer to the care plan/Kardex for planned interventions, updating and revision of care plans, the need to conduct thorough investigation of incidents to establish root cause, and initiate a new intervention to address causative or contributing factors following an incident or accident. 7). Review of post tests on the above topics, revealed nursing staff had passed the post test on 06/15/2021. 8). Review of the documentation provided for the audit revealed no identified concerns. Interview with the Clinical Nurse Consultant, on 07/19/2021, at 4:02 PM, revealed while conducting the audits no concerns were identified at this time. 9). Review of the QAPI meeting, revealed the facility conducted the meeting on 07/13/2021, with no identified concerns. 10). Interviews on 07/19/2021, at 1:40 PM with LPN #5, 8:51 AM with LPN #6, and 9:01 AM with LPN #1, revealed they received education on the facility's policies and procedures regarding development and implementation of person-centered care plans. Interviews on 07/20/2021, at 9:09 AM with SRNA #11, at 9:21 AM with SRNA #16, at 9:27 AM with SRNA #15, revealed they received education on the facility's policies and procedures regarding development and implementation of person-centered care plans. 11). Review of the 07/13/2021 facility QAPI meeting documentation, revealed available QAPI team members met with Medical Director (proxy) via telephone to initiate Root Cause Analysis and to implement a QAPI Action Plan. The plan was reviewed and revised by the complete Inter Disciplinary Team and by the Medical Director (proxy) on 07/13/2021. The Inter Disciplinary Team and Medical Director will attend QAPI meeting to review the efficacy of the aforementioned plan weekly x 4 weeks, then bi-weekly x 1 month, then monthly thereafter to ensure continued compliance with the requirements of participation. The IDT included the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admissions Coordinator, Staff Development Coordinator, Housekeeping Director, Maintenance Director, MDS Nurse, Dietary Director, and Medical Director.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent accidents. The facility assessed Resident #1 to be at risk for falls. Resident #1 sustained fractures from a fall on 02/15/2021, while reaching for the call light. After the fall on 02/15/2021, the facility updated the resident's care plan to keep the residents call light within reach and to frequently check placement. However on 02/21/2021, at 3:50 PM, the resident was again reaching for his/her call light and fell from the bed. The resident was sent to the emergency room where he/she was diagnosed with a right nasal fracture. The findings include: Review of facility's policy, Falls, Fall Risk, Managing, revised 2018, revealed based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of Resident #1's closed record revealed the facility admitted the resident on 01/26/2021, with diagnoses which included [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction Affecting the Left Side Non-Dominant Side, Pain Left Hip, Major Depressive Disorder, Generalized Anxiety Disorder, [CONDITION(S)], [CONDITION(S)], Unspecified, Personal History of [CONDITION(S)] and Cerebral Infarction without Residual Deficits. Review of Resident #1's Admission Minimum Data Set (MDS) assessment, dated 02/01/2021, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident had cognitive impairment. The MDS also revealed the resident required the assistance of two (2) staff for bed mobility, transfers, dressing and toilet use. In addition, further review of the MDS revealed the resident's balance during transitions was not steady, he/she was only able to stabilize with staff assistance. Review of a Fall Risk Assessment for Resident #1, dated 01/26/2021, revealed the facility assessed the resident to be a high risk for falls with a fall risk score of ten (10). Review of Resident #1's Comprehensive Care Plan, dated 02/04/2021, revealed the facility initiated fall interventions that included, encourage rest periods as needed to avoid over-tiring, encourage to wear non-skid footwear as much as resident chooses to comply, keep frequently used items within reach, observe for acute process, and notify MD, therapy to screen as needed, and verbal reminders not to attempt independent transfers. Review of a facility fall's investigation dated, 02/15/2021 at 11:30 PM, revealed the facility determined the cause of the fall was the resident's call light was not within reach. Further review of the investigation revealed the interventions included to keep the call light clipped to the resident and to keep the bed in the low position. Record review revealed the facility transferred Resident #1 to an acute care emergency room (ER) on 02/18/2021, related to the 02/15/2021 fall. Review of the facility's fall investigation, dated 02/21/2021 at 3:50 PM, revealed State Registered Nurse Aide (SRNA) #7 answered the resident's call light and found him/her on the floor with the call light attached to his/her gown. SRNA #7 revealed the resident's bed was not in the low position. Review of the emergency room record, dated 02/18/2021, revealed Resident #1 had sustained a left humeral head fracture, fracture of [MEDICATION(S)] vertebra 12, Lumbar 4 and 5 vertebra, as a result of the fall on 02/15/2021. Further review of the record, revealed he/she was to follow up with orthopedics as needed for the shoulder fracture and follow up with neurosurgery for spine fractures. Review of the record, revealed the resident was bedbound with instructions for the resident not to be lifted into the wheelchair and be upright. Continued review revealed the Advanced Practice Registered Nurse, (APRN) initialed and dated the instructions on 02/19/2021. Review of the emergency room record, dated 02/21/2021, revealed Resident #1 had sustained a right nasal bone fracture, as a result of the fall on 02/21/2021. Review of Advanced Practice Registered Nurse, (APRN) #2's Progress Note, dated 02/17/2021, revealed she had seen Resident #1 related to the fall on 02/15/2021 and had ordered x-rays of the left shoulder and left hip. Further review of the note, revealed the resident's pain was sudden, onset from the fall and x-rays had not been done. Further review of the note, revealed she was notified on 02/18/2021 x-rays had not been obtained due to inclement weather and Resident #1 was sent to the emergency room for further evaluation. Interview with Licensed Practical Nurse (LPN) #2, on 06/07/2021 at 4:30 PM, revealed on 02/15/2021, SRNA #2 had been in the resident's room just a few minutes before. He stated the resident's call light came on and showed on the panel it had been pulled from the wall. LPN #2 stated the resident was found on the floor and had been reaching for the call light. He further stated he assessed the resident and he/she denied any pain at that time. The LPN stated the resident was assisted back to bed and there were no signs of pain. LPN #2 further stated the resident had a skin tear in which he cleansed and dressed. He stated by the end of the shift, Resident #1 was complaining of left shoulder pain and it was reported to RN (Registered Nurse) #2. LPN #2 stated there were no specific interventions in place before the fall. He stated his intervention was to initiate a low bed. He further revealed the resident was constantly using the call light and requesting Tylenol. Interview with State Registered Nurse Aide, (SRNA) #2, on 06/03/2021 at 4:50 PM, revealed on 02/15/2021, he and another SRNA were providing care for another resident when Resident #1's call light went off. He stated when he arrived the resident was on the floor near the recliner and his/her call light was on the floor. SRNA #2 further stated the resident was crying and had a skin tear to his/her right hand and they called for a nurse. He stated the nurse assessed the resident and assisted him/her back to bed. SRNA #2 stated the resident had no complaints of pain. However, at the end of the shift the resident was complaining of pain to his/her left shoulder. He stated the resident transferred with assist of two (2) staff, but after the fall he/she was total assist with a maxi lift (mechanical lift). Interview with Registered Nurse (RN) #2, on 06/01/2021 at 2:35 PM, revealed on 02/16/2021, LPN #2 had reported the resident had fallen and the resident had an order for Tylenol as needed, but no routine orders for pain medication. She further stated she contacted Mobile-x-ray after receiving the order from the APRN; however, they were not able to come out due to the icy road conditions. RN #2 stated the resident continued working with therapy and staff continued to transfer the resident to the wheel chair after his/her fall on 02/15/2021. RN #2 stated a Physician's Order was required for a resident not to transfer after a fall with possible injury. She stated the Director of Nursing had placed a Panacea Perimeter Defined Mattress (foam mattress with defined edges), on Resident #1's bed, but she was not aware of any other interventions in place. Further interview revealed Mobile-x-ray services kept saying they were coming but they didn't. RN #2 stated the resident's son wanted the resident sent to the emergency room . She revealed the physician had given an order for pain medication but Resident #1 had diagnosis of [CONDITION(S)] and could not take what was ordered, so she notified the physician's office but they were closed. RN #2 states she passed it to the night shift nurse to follow up. RN #2 stated on the 8th, the facility sent the resident to the emergency room and (he/she) returned with shoulder and back fractures. She stated the resident was to see a spine specialist and orthopedic physician. The RN stated, I don't recall seeing anything that said (he/she) wasn't to be transferred to the wheelchair. Further interview revealed she had assessed Resident #1, however there was no documentation/progress note's related to the fall, pain or new interventions. Interview with APRN #2, on 06/04/2021 at 10:10 AM, revealed she was not in the facility at the time of the fall. She stated she had given the order on 02/16/2021 for Resident #1 to have x-rays of the left shoulder and left hip, however, it had not been obtained due to the icy roads and the resident was transferred to theER on [DATE] for further evaluation. APRN #2 further stated the x-rays revealed the resident had sustained several fractures. Interview with SRNA #7, on 06/07/2021 at 4:05 PM, revealed on 02/21/2021, she was returning from break and Resident #1's call light was on so she went to answer it. She stated Resident #1 was on the floor beside the bed with the call light call in his/her hand. She further revealed the call light had been pulled from the wall when the resident fell . SRNA #7 stated Resident #1 was laying on his/her back on the right side of the bed. In addition, she stated she yelled for LPN #3, who was in the hall and asked the resident to be still. SRNA #7 revealed Resident #1 was bleeding from his/her nose and LPN #3 came and assessed him/her. She stated she thought the nurse had called EMS (Emergency Medical Services). She further revealed Resident #1 stayed on the floor until the ambulance arrived. She stated Resident #1 was crying and upset. SRNA #7 revealed Resident #1 was in bed but the bed was not low to the floor. Interview with LPN #3, on 06/07/2021 at 4:21 PM, revealed on 02/21/2021, SRNA #7 reported to her the resident had fallen out of the bed. She stated Resident #1 had a nose bleed, but did not want to go to the hospital. LPN #3 stated she called the Advanced Practice Registered Nurse and EMS and made the resident comfortable on the floor until EMS arrived. LPN #3 further stated she thought there was a perimeter defined mattress on the resident's bed, but the resident was not on a low bed. LPN #3 further stated the resident would always ask for Tylenol and the call light. LPN #3 stated she completed the Morse Fall Risk assessment, the fall investigation form, incident report and made a progress note for the fall that occurred on 02/21/2021. Interview with Director of Nursing (DON), on 06/04/2021 at 12:04 PM, revealed Resident #1 would hold the call light in his/her hand and was always asking about the call light. She stated a blue bed throw was used on the bed to help Resident #1 see the white call light and she had put a perimeter defined mattress on the resident's bed. The DON stated she expected the nurses to assess the residents and document post fall follow up notes for seventy-two (72) hours. She further revealed Resident #1 should have been assessed and charted on every shift for fall related follow up. Interview with the Administrator, on 06/16/2021 at 11:06 AM, revealed he expected any change in a resident's condition to be reported to the DON. He stated the report would then be discussed with the Interdisciplinary Team for action to be taken. **The facility implemented the following actions to remove Immediate Jeopardy: 1). The ADON, Clinical Director, Clinical Nurse Consultant, Infection Preventionist, Admissions Nurse, and MDS Nurse reviewed all current residents' Fall Risk Evaluations on 07/12/2021, to ensure they accurately reflected the residents status. 2). The Clinical Nurse Consultant, ADON, MDS, Infection Preventionist, and Admission Nurse, completed a 100% audit of all care plans of resident's with high risk for falls to confirm adequate supervision, appropriateness of interventions, and assistive devices were in place as needed on 07/12/2021. 3). The incident investigations for current residents who experienced falls in the prior 60 days, were audited to verify that appropriate interventions were implemented based on the investigation findings. This audit was completed by Clinical Nurse Consultant by 07/01/2021. Any needed changes to interventions or care plans were revised at that time. 4). All assistive devices in place as fall interventions, including but not limited to beds in low position, were inspected to verify placement and function by Clinical Nurse Consultant on 07/13/2021. . 5). All call lights were inspected to verify they functioned and alarmed as designed by Maintenance Director on 07/13/2021. 6), Education and in-service training were provided to nursing staff on areas for opportunity to include topics of: requirement to refer to the care plan/Kardex for planned interventions, updating and revision of care plans, the need to conduct thorough investigation of incidents to establish root cause, and initiate a new intervention to address causative or contributing factors following an incident or accident. The education was provided by DON, ADON, SDC, or Clinical Nurse Consultants on 06/15/2021, 06/16/2021, 06/17/2021 and 06/18/2021. The Clinical Directors (CD), Assistant Director of Nursing (ADON) and Director of Nursing (DON) were educated regarding review of incident investigations for completion and to validate that the intervention was appropriate for the root cause, had been added to the care plan, and was implemented. This education was provided on 06/14/2021 by the Clinical Nurse Consultant. Any staff that had not completed education by 06/18/2021 was not permitted to work until training was completed. 7). Post tests were administered on the above topics by the DON, ADON, SDC, and Clinical Directors, and Clinical Nurse Consultants beginning on 06/15/2021 with 100% score attained. 8). The facility would also implement monitoring measures and random audits spread over the course of the next 90 days to ensure compliance and efficacy of this plan. Any negative areas identified during audits will be immediately corrected at that time. 9). All audit results would be shared with the facility Quality Assurance Performance Improvement (QAPI) team and the Medical Director no less than monthly for review. All negative audit results will be immediately brought before the QAPI team and Medical Director for immediate review and remedy. 10). On 06/15/2021, the Administrator and DON gathered the facility's policies and procedures regarding development and implementation of person-centered care plans and began 100% in-servicing of all nursing staff on this topic. Continuing sessions of the education were provided by trained department managers as well as Administrative Nursing Leaders, Staff Development Coordinator, and Clinical Nurse Consultants on 06/15/2021, 06/ 1, 06/17/2021, and 06/18/2021. Post test administered upon completion of this training with scores of 100% attained. Starting on 06/18/2021, no clinical staff will be permitted to work until education and post-test have been completed. These topics were added to clinical new hire orientation effective 07/13/2021. Compliance would be ensured and tracked by each employee's respective department manager. 11). On 07/13/2021, available QAPI team members met with Medical Director (proxy) via telephone to initiate Root Cause Analysis and to implement a QAPI Action Plan. The plan was reviewed and revised by the complete Inter Disciplinary Team and by the Medical Director (proxy) on 07/13/2021. The Inter Disciplinary Team and Medical Director will attend QAPI meeting to review the efficacy of the aforementioned plan weekly x 4 weeks, then bi-weekly x 1 month, then monthly thereafter to ensure continued compliance with the requirements of participation. The IDT included the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admissions Coordinator, Staff Development Coordinator, Housekeeping Director, Maintenance Director, MDS Nurse, Dietary Director, and Medical Director. ** The State agency verified the facility's corrective action as follows, and determined the facility removed the immediate jeopardy on 07/14/2021 as alleged. 1). Review of all current residents' Fall Risk Evaluations dated 07/12/2021, revealed they were reviewed by the ADON, Clinical Director, Clinical Nurse Consultant, Infection Preventionist, Admissions Nurse, and MDS Nurse Interviews with the MDS Nurse, on 07/12/2021 at 11:23 AM and the ADON on 07/12/2021 at 3:22 PM, verified they had reviewed all current resident's Fall Risk Evaluations the for all residents. 2). Review of care plans of current residents identified at high risk for falls, revealed the Clinical Nurse Consultant, ADON, MDS, Infection Preventionist, and Admission Nurse, completed audits of all care plans of current residents with high risk of falls to ensure accuracy of the fall interventions on 07/12/2021. 3). Review of incident investigations for current residents who experienced falls in the prior 60 days, revealed the Clinical Nurse Consultant completed audits by 07/01/2021, to verify appropriate interventions were implemented based on the investigation findings. 4). Review of a audit tool of interventions, dated 07/13/2021, revealed all assistive devices in place as fall interventions, including but not limited to beds in low position, were inspected to verify placement and function by the Clinical Nurse Consultant. Interview with the Clinical Nurse Consultant, on 07/19/2021 at 4:02 PM, verified she had inspected all assistive devices in place as fall interventions, to check placement and function. 5). Review of a call light audit tool, dated 07/13/2021, revealed the Maintenance Director had inspected all call lights to verify they were functioning and alarmed as designed. 6). Review of the education rosters, dated 06/15/2021 through 08/18/2021, revealed the DON, ADON, SDC, or Clinical Nurse Consultants educated nursing staff on areas for opportunity to include topics of: requirement to refer to the care plan/Kardex for planned interventions, updating and revision of care plans, the need to conduct thorough investigation of incidents to establish root cause, and initiate a new intervention to address causative or contributing factors following an incident or accident. Review of the education roster, dated 06/14/2021, revealed the Clinical Nurse Consultant educated the Clinical Directors, ADON, and DON, regarding review of incident investigations for completion and to validate the intervention were appropriate for the root cause, had been added to the care plan, and were implemented. Interviews on 07/19/2021 at 3:15 PM with the ADON and at 1:56 PM, with the Clinical Director, revealed they received education from the Clinical Nurse Consultant on incident investigations for completion, validating the intervention were appropriate for the root cause, had been added to the care plan, and were implemented. Interviews on 07/19/2021 at 1:40 PM, with LPN #5, 8:51 AM, with LPN #6, and 9:01 AM, with LPN #1, revealed they received education from the DON, ADON, SDC, or Clinical Nurse Consultants on areas for opportunity to include topics of: requirement to refer to the care plan/Kardex for planned interventions, updating and revision of care plans, the need to conduct thorough investigation of incidents to establish root cause, and initiate a new intervention to address causative or contributing factors following an incident or accident. 7). Review of post tests on the above topics, revealed nursing staff had passed the post test on 06/15/2021. 8). Review of the documentation provided for the audit revealed no identified concerns. Interview with the Clinical Nurse Consultant, on 07/19/2021, at 4:02 PM, revealed while conducting the audits no concerns were identified at this time. 9). Review of the QAPI meeting, revealed the facility conducted the meeting on 07/13/2021, with no identified concerns. 10). Interviews on 07/19/2021, at 1:40 PM with LPN #5, 8:51 AM with LPN #6, and 9:01 AM with LPN #1, revealed they received education on the facility's policies and procedures regarding development and implementation of person-centered care plans. Interviews on 07/20/2021, at 9:09 AM with SRNA #11, at 9:21 AM with SRNA #16, at 9:27 AM with SRNA #15, revealed they received education on the facility's policies and procedures regarding development and implementation of person-centered care plans. 11). Review of the 07/13/2021 facility QAPI meeting documentation, revealed available QAPI team members met with Medical Director (proxy) via telephone to initiate Root Cause Analysis and to implement a QAPI Action Plan. The plan was reviewed and revised by the complete Inter Disciplinary Team and by the Medical Director (proxy) on 07/13/2021. The Inter Disciplinary Team and Medical Director will attend QAPI meeting to review the efficacy of the aforementioned plan weekly x 4 weeks, then bi-weekly x 1 month, then monthly thereafter to ensure continued compliance with the requirements of participation. The IDT included the Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admissions Coordinator, Staff Development Coordinator, Housekeeping Director, Maintenance Director, MDS Nurse, Dietary Director, and Medical Director.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to inform the physician when a change in condition occurred for one (1) of three (3) sampled residents (Resident #2). Review of the resident's food and fluid records dated 03/17/2021 through 05/04/2021, revealed Resident #2 had decreased fluid intake and was not meeting his/her assessed fluid needs. However, the facility failed to recognize the resident's decreased intake and did not notify the resident's physician. On 05/04//2021, the facility transferred Resident #2 to the hospital for evaluation and treatment after staff noted a mental status change. The hospital admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy, Change in a Resident's Condition or Status, dated May 2017, revealed staff would notify the resident's attending physician and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Further review of the policy revealed a significant change in condition was a major decline or improvement in the resident's status that: wouldn't normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions; impacted more than one area of the resident's health status; and, required interdisciplinary review and/or revision of the care plan. Continued review of the policy revealed nursing staff would make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact Situation, Background, Assessment, Recommendation (SBAR) Communication form. Review of Resident #2's closed record revealed the facility admitted the resident on 03/16/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the facility assessed the resident to require the limited assistance of one (1) staff with eating, and extensive assistance of two (2) staff was required for transfers, bed mobility and toileting. Review of a Nutritional Risk Assessment completed for Resident #2, on 03/28/2021, revealed the resident's assessed fluid need was 1700-1900 milliliters (ml) per day, assessed calorie need was 1814-2100 calories per day, and the resident required 60-72 grams of protein per day. Further review of the assessment revealed the resident consumed 26-50% of meals. Review of Resident #2's Comprehensive Care Plan, dated 03/23/2021, revealed the resident required staff assistance of one person with meals. The care plan further revealed Resident #2 as having a nutritional problem and the goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within three (3) pounds, no signs and symptoms of malnutrition and consuming at least fifty (50) percent of meals thru review date of 06/20/2021. Continued review of the care plan revealed interventions included staff to encourage good fluid intake and offer substitutes for foods not eaten or disliked, monitoring for signs and symptoms of malnutrition, emaciation, muscle wasting, and significant weight loss; three (3) pounds in one week, greater than five (5) percent in one month, greater than 7.5% in three (3) months and greater than 10% in six (6) months, monitor the resident for signs and symptoms of dysphagia, refusing to eat, and holding food in mouth, obtain and monitor laboratory values, reporting to physician and follow up as needed. Review of Resident #2's recorded fluid intakes from 03/17/2021 through 05/04/2021, revealed a out of a total of forty-nine days, there were only four (4) days, Resident #2 met his/her minimum fluid requirements of 1700-1900 ml's. Further review revealed that for forty-five (45) days, Resident #2 was under the minimum requirements of 1700 ml/day, with the amounts ranging from 120 ml's in a day to 1570 mls in a day. However, there was no documented evidence the facility monitored the decreased fluid intake. There was no documented evidence the resident's physician was notified that Resident #2 was not consuming fluids. Review of Resident #2's food intake records, for the one-hundred and forty-six (146) meals from 03/16/2021 through 05/04/2021, revealed the resident refused to eat six (6) of the meals, consumed 50 percent or less for seventy-eight (78) of the meals and consumed greater than fifty percent for sixty-two (62) meals. However, there was no documented evidence the facility notified the resident's physician that Resident #2 was not eating well. Review of Resident #2's weight record, from 03/18/2021 through 04/26/2021, revealed the resident had a severe weight loss of 10.9% percent. However, there was no documented evidence the facility notified the resident's physician of the resident's weight loss. Review of a Nurse's Progress Note, dated 05/04/2021 at 12:54 PM, recorded by Licensed Practical Nurse (LPN) #4, revealed the APRN (Advanced Practice Registered Nurse) assessed Resident #2 to be with altered mental status and labored breathing. Further review revealed the facility transferred the resident to the emergency room for evaluation and treatment. Review of the clinical record revealed on 05/04/2021, the facility transferred the resident to the hospital due to altered mental status. Review of laboratory results from the 05/04/2021 hospital visit revealed the resident's Blood Urea [MEDICATION(S)] (BUN) level was high at 70 milligrams per deciliter (mg/dL) (normal range 7-25 mg/dL) and his/her Creatinine level was high at 1.79 mg/dL (normal range 0.50-1.20 mg/dL), and Potassium Level 8.0 mg/dL (normal range 3.5 - 5.2 mg/dL). Review of the Hospital Admission History and Physical dated 05/04/2021, revealed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Licensed Practical Nurse (LPN) #4, on 06/07/2021 at 4:49 PM, revealed Resident #2 was on [MEDICATION(S)] for appetite so she assumed Resident #2 had a poor appetite when he/she was admitted . LPN #4 stated she had not reported the resident's poor fluid and food intake to the APRN or the resident's physician. She stated if the resident had refused all three (3) meals in a single day, she would have notified the resident's physician. Continued interview revealed their baseline was a resident could go a day without eating two (2) meals. LPN #4 further stated she could not recall any of the State Registered Nurse Aides (SRNA) telling her Reesident #2 was not eating or drinking. Interview with APRN #2, on 06/07/2021 at 1:42 PM, revealed she was aware of a decline in the resident's meal intake, but she was not aware of the resident's poor fluid intake. In addition, she stated she was not made aware of the resident's severe weight loss. APRN #2 stated she usually communicated with the physician. However, there was no documented evidence to indicate that the physician had been made aware of the resident's severe weight loss. APRN #2 stated she would have expected the nursing staff to inform her when residents had poor fluid intake and a change in their condition. Interview with Resident #2's Physician, on 06/05/2021 at 11:40 AM, revealed the APRN and the nursing staff did communicate with her. She further revealed Resident #2 became acutely ill quickly and they sent him/her out to the hospital. She further revealed she was not at her office and could not answer questions related to Resident #2's severe weight loss. However, record review revealed no documented evidence the facility had notified Resident #2's Physician. Interview with the Director of Nursing (DON), on 06/08/2021 at 12:20 PM, revealed she expected the SRNA's to inform the nurse if a resident was not eating or drinking. The DON stated she expected the nurse to inform the Clinical Director, Dietician and the APRN or the resident's physician of changes. She further stated outcomes for not monitoring intakes could be very negative. Interview with the Administrator, on 06/16/2021 at 11:06 AM, revealed he expected any change in a resident's condition to go up the ladder to the DON so that it could be discussed with the Interdisciplinary Team. He stated he expected the nurses to notify the physician when a change had occurred.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). On 02/15/2021 at 11:30 PM, Resident #1 sustained a left humeral head fracture, T-12, L-4 and L-5 fractures to the spine. Resident #1 was noted to be in pain and the pain was documented as being six (6) out of ten (10) on the pain scale on 02/16/2021. Staff interviews revealed the resident had increased and new complaints of pain to the left shoulder and left hip. However, additional pain medication ([MEDICATION(S)]) was ordered for the resident after the injury, but due to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order for [MEDICATION(S)] 5/325 milligrams (mgs) was received. However, the facility failed to ensure the resident received the pain medication. The findings include: Review of the facility's policy, Pain Management, updated June 2021, revealed medications would be administered based on evaluated levels of pain and by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's closed record revealed the facility admitted the resident on 01/26/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident had cognitive impairment. The facility also assessed the resident to require the extensive (weight bearing) assistance of two (2) staff for transfers, bed mobility, and toilet use. Closed record review revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note, dated 02/16/2021, revealed the physician was made aware of the fall and the resident's complaints of pain to the left hip and new pain to the left shoulder. Further review revealed on 02/16/2021 at 4:26 PM, the physician ordered [MEDICATION(S)], if no seizures or allergies. Further review of the Progress Note revealed Registered Nurse (RN) #2, reviewed the chart and noted a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 attempted to notify the physician's office at 4:30 PM, without success and since the pain was currently controlled with Tylenol, she would notify doctor's office the next day. Review of RN #2's Progress Note dated 02/17/2021 at 3:20 PM, revealed Resident #1 told RN #2 the Tylenol did help but, it did not last very long. Further review of the note revealed a new order for [MEDICATION(S)] 5/325 mg every six hours was obtained at 4:48 PM. Further review of revealed at 5:21 PM, the Pharmacy was contacted to obtain a verification number to remove the [MEDICATION(S)] from the Emergency Drug Kit (EDK) and a message was left with the pharmacy. However, the pharmacy did not respond to give the verification number; Resident #1 did not receive the [MEDICATION(S)] until 02/19/2021. Review of the Advanced Practice Registered Nurse (APRN) Note, dated 02/17/2021, revealed Resident #1 was complaining of left shoulder pain and left hip pain. Resident #1's left hip and left shoulder pain was sudden in onset from a fall and was tender to palpation. Review of APRN Note, dated 02/19/2021, revealed the resident was sent to the emergency department (ED) on 02/18/2021 for further evaluation of the left hip and shoulder. The note further revealed the APRN was made aware on 02/18/2021 the x-rays ordered on 02/16/2021 for Resident #1 had not been done due to inclement weather. Further review of the note revealed the APRN had reviewed the ED records and the x-rays revealed a left humeral head fracture, closed, left closed fracture of T12, L4, L5. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Three (3) doses were given for general pain, two (2) doses for left hip pain, one (1) dose for back pain (new location) and three (3) doses for left shoulder pain (new location). The resident rated his/her pain from 2-6 on a scale of 1-10. Further review of the MAR, revealed [MEDICATION(S)] 5/325 ([MEDICATION(S)] 5 mg and Acetaminophen 325 mg) four (4) doses were administered from 02/19/2021 - 02/21/2021 for back pain. It was noted on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital medical record revealed that x-rays confirmed a humeral head fracture, left closed initial encounter, other closed fracture of the 12th [MEDICATION(S)] vertebra, fourth lumbar vertebra, and fifth lumbar vertebra. The Physician's Assistant (PA) indicated he had placed instructions in Resident #1's paperwork for the nursing home to honor so that Resident #1 was not lifted into the wheelchair and upright. Resident #1 was prescribed [MEDICATION(S)] to be given every six hours as needed for pain. Interview with Family Member (FM) #1, on 06/01/2021 at 7:22 PM, revealed Resident #1 was complaining of pain following the 02/15/2021 fall from the bed. The family member further revealed the facility allowed the resident be in pain and were only giving him/her Tylenol. The family member stated RN #2 had told them the physician had ordered pain medication ([MEDICATION(S)]) and the family member told RN #2 the resident could not take it because he/she had seizures. The family member stated they told RN #2 this information should have been communicated to the physician when the pain medication was requested, The family member further revealed staff continued to transfer Resident #1 to the wheelchair and continued therapy without knowing if he/she had fractures. Family Member #1 further revealed she observed the resident up in the wheelchair crying in pain during a window visit. Interview with State Registered Nurse Aide, (SRNA) #2, on 06/03/2021 at 4:50 PM, revealed on 02/16/2021, the resident had no complaints of pain at the time of the fall but by the end of the shift he/she was complaining of left shoulder pain. SRNA #2 stated the resident would frequently ask for Tylenol many times during the shift even prior to the fall. Interview with SRNA #1, on 06/02/2021 at 2:56 PM, revealed Resident #1 required two (2) assist with transfers. SRNA #1 revealed she was told in report upon returning to work that Resident #1 had a fall while looking for his/her call light. She stated Resident #1 complained of hip pain before and after the fall. Interview with Licensed Practical Nurse (LPN) #2 on 06/07/2021 at 4:30 PM, revealed he was the nurse on duty on 02/15/2021. He revealed he had assessed the resident and initially the resident denied having pain. However, LPN #2 stated at the end of his shift the resident had began complaining of left shoulder pain and he made the oncoming nurse (RN #2) aware. Interview with RN #2, on 06/01/2021 at 2:35 PM, revealed on 02/15/2021 she received report from LPN #2 that Resident #1 had a fall. RN #2 further revealed Resident #1 complained of pain frequently. RN #2 stated Resident #1 had as needed Tylenol ordered but nothing routinely given. On 02/16/2021, the APRN gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview with RN #2 revealed the physician had given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she notified the physician's office but they had left for the day. RN #2 revealed Resident #1's pain seemed to be controlled with Tylenol so she noted she would attempt to call the next day. She further stated she did not notify the APRN or the medical director that Resident #1 required a different pain medication. RN #2 noted on 02/17/2021 at 3:47 PM, the resident had stated the Tylenol helped but, wears off too quickly. Additional interview with RN #2, on 06/01/2021 at 2:35 PM, revealed on 02/17/2021 at 4:48 PM, the physician gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed on 02/18/2021 at 10:30 AM, the son had requested Resident #1 be sent to the emergency room . Resident #1 returned to the facility with a left shoulder fracture and back fractures. She stated Resident #1 was to see a spine specialist and orthopedic physician. RN #2 revealed she did not note any order stating the resident was not to be transferred to the wheelchair. Interview with the Director of Nursing (DON), on 06/04/2021 at 12:08 PM, revealed she expected the nurses to assess residents for pain. She further revealed the resident had pain constantly. The DON stated she expected the nurse to document when residents had pain and what they did to address it. She stated the Medical Director was always available if the APRN or primary care physician was unable to be reached. Interview with the Administrator, on 06/16/2021 at 11:06 AM, revealed he expected any change in a resident's condition to go up the ladder to the DON so that it could be discussed with the Interdisciplinary Team. He revealed he expected the nurses to notify the physician when a change had occurred.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents identified at nutritional risk were monitored and provided nutritional services to meet the needs of the resident to prevent severe weight loss for one (1) of three (3)sampled residents (Resident #2). Record review revealed from 03/16/2021 through 05/4/2021, Resident #2 did not meet his/her fluid or nutritional needs. Staff completed a hydration and nutrition risk assessment during this time frame; however, the facility failed to identify the resident was at risk for dehydration and was malnourished. Resident #2 was transferred to the hospital 05/04/2021. The resident's labs were assessed to be critical. Resident #2 was diagnosed with Metabolic Acidosis, Severe [CONDITION(S)], [CONDITION(S)], Acute Kidney Injury and Severe Malnutrition. The findings include: Review of the facility's policy, Resident Hydration and Prevention of Dehydration, dated October 2017, revealed facility staff would strive to provide adequate hydration and to prevent and treat dehydration. The dietician would assess all residents for dehydration as part of the comprehensive assessment, at least quarterly and more often as necessity per the resident's needs. Minimum fluids would be calculated and documented on initial, annual and significant change assessments using current standards of practice. Further review of the policy revealed nursing staff would assess for signs and symptoms of dehydration during daily care, Nurse Aides would report intake less than 1200 ml (milliliters) per day to the nursing staff and laboratory test may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration. If laboratory test were consistent with actual dehydration, the physician would initiate intravenous (IV) hydration. Continued review of the policy revealed nursing would monitor and document fluid intake and the dietician would be kept informed of the resident's status. The Interdisciplinary Team would update the care plan and document the resident's response to interventions until the team agreed that fluid intake and relating factors were resolved. Review of the facility's policy Weight Assessment and Intervention, dated September 2008, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff would measure weights on admission and weekly for two (2) weeks thereafter. If no weight concerns were noted at this point, weights would be measured monthly thereafter. Any weight of five percent (5%) or more since last weight assessment would be retaken the next day for confirmation. If the weight were verified, nursing would notify the dietician. The Dietician would review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends would be re-evaluated by the treatment team member whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss would be based on the following criteria: a. One (1) month - five percent (5%) weight loss was significant; greater than five percent (5%) was severe, b. Three (3) months - seven and one half (7.5%) weight loss was significant; greater than seven and one half (7.5%) was severe, c. Six (6) months - ten percent (10%) weight loss was significant; greater than ten (10%) was severe. Review of Resident #2's closed record revealed the facility admitted the resident on 03/16/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission Minimum Data Set (MDS) assessment, dated 03/22/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the facility assessed the resident to require the limited assistance of one (1) staff with eating, and extensive assistance of two (2) staff for transfers, bed mobility and toileting. Review of Resident #2's weight record revealed on 03/17/2021, the admission weight was 137 pounds, on 03/18/2021 - 138.5 pounds, re-weight on 03/18/2021 was 133.5 pounds, on 03/20/2021 - 133.0 pounds, on 03/25/2021, 127.0 pounds a 7.29% weight loss in eight (8 days. Further review of the resident's weight record revealed he/she weighed 122.0 pounds on 04/26/2021, a fifteen (15) pound weight loss, 10.9 % since admission to the facility on [DATE]. However, further review of the record revealed no documented evidence Resident #2's care plan had been revised to address the resident's weight loss. Review of a Nutritional Risk Assessment completed for Resident #2, on 03/28/2021, revealed the resident's assessed fluid need was 1700-1900 milliliters (ml) per day, assessed calorie need was 1814-2100 calories per day, and the resident required 60-72 grams of protein per day. Further review of the assessment revealed the resident ate 26-50% of meals. Review of Resident #2's Comprehensive Care Plan, dated on 03/23/2021, revealed the resident required staff assistance of one person with meals. The care plan further revealed Resident #2 was assessed to be nutritionally at risk and the goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within three (3) pounds, no signs and symptoms of malnutrition and consume at least fifty (50) percent of meals through review date of 06/20/2021. Continued review of the care plan revealed staff would encourage good fluid intake and offer substitutes for foods not eaten or disliked, monitor for signs and symptoms of malnutrition, emaciation, muscle wasting, and significant weight loss, three (3) pounds in one week, greater than five (5) percent in one month, greater than 7.5% in three (3) months and greater than 10% in six (6) months, monitor the resident for signs and symptoms of dysphagia, refusing to eat, and holding food in mouth, obtaining and monitoring laboratory values, reporting to physician and following up as needed. Review of Resident #2's recorded fluid intakes from 03/17/2021 through 05/04/2021 (a total of forty-nine days), revealed Resident #2 met the minimum fluid requirements of 1700-1900 ml's for only four (4) of the forty-five (45) days. Further review revealed Resident #2 was under the minimum requirements of 1700 ml/day, the intake ranged from 120 mls in a day to 1570 mls in a day. Review of Resident #2's food intake records, for the one-hundred and forty-six (146) meals from 03/16/2021 through 05/04/2021, revealed the resident refused to eat six (6) of the meals; consumed 50 percent or less for seventy-eight (78) of the meals; and, consumed greater than fifty percent for sixty-two (62) meals. However, there was no documented evidence found in the resident's medical record to indicate the facility notified the resident's physician that Resident #2 was not eating very well. Review of a Nurse's Progress Note for Resident #2, dated 05/04/2021 at 12:54 PM, revealed the facility transferred the resident to the emergency room for evaluation and treatment. The Advance Practice Registered Nurse (APRN), during routine rounds on 05/04/2021, assessed Resident #2 to be with altered mental status and labored breathing. Record review revealed on 05/04/2021, the resident was transferred to the hospital due to altered mental status. Review of laboratory results from the 05/04/2021 hospital visit revealed the resident's Blood Urea [MEDICATION(S)] (BUN) level was high at 70 milligrams per deciliter (mg/dL) (normal range 7-25 mg/dL) and his/her Creatinine level was high at 1.79 mg/dL (normal range 0.50-1.20 mg/dL), Potassium Level 8.0 milligrams per deciliter (normal range 3.5 - 5.2 mg/dL). Further review of the Hospital Admission History and Physical on 05/04/2021, revealed Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's medical record revealed no documented evidence staff assessed the resident's nutrition/hydration status (mucous membranes, skin turgor, etc.) nor notified the physician or dietician of the resident's decreased nutrition and hydration status. Interview with State Registered Nurse Aide (SRNA) #1, on 06/02/2021 at 2:56 PM, revealed she recalled Resident #2 required assistance of one staff with bed mobility, was able to feed himself/herself, and he/she did not eat well. She further revealed Resident #2 was able to make his/her needs known and would ask for water. She did not recall reporting the resident's decreased meal/fluid intake to nurse. Interview with SRNA #8, on 06/07/2021 at 7:04 PM, revealed SRNA's documented the resident's meals and fluid intakes in the Kiosk and someone looked at that every day. She further revealed she would report to the nurse if a resident was not eating or drinking. Interview with Licensed Practical Nurse (LPN) #4, on 06/07/2021 at 4:49 PM, revealed the resident was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further revealed she would report to the ARNP if a resident refused all meals in a day. She stated the aides record resident meal and fluid intakes on the Kiosk, but could not recall if the system alerted staff if a resident's had poor consumption. LPN #4 stated Resident #2 seemed fine that morning. She stated she did not recall seeing the resident's recent lab results, as they would go in a binder for the ARNP to review and once the labs were signed off they went in the chart with any new orders. Interview with the Clinical Director, who was responsible for monitoring the resident's meal intake, on 06/04/2021 at 9:34 AM, revealed the facility had weekly clinical meetings to discuss residents on weekly weights, weight loss, wounds, and other concerns. She revealed she was not aware of the resident's weight loss until the weekly meeting at the end of April. She further stated the resident should have been on weekly weights. The Clinical Director stated the aides document intakes in the Kiosk and she expected to be made aware if a resident was not eating or drinking. Interview with the Assistant Director of Nursing (ADON) on 06/08/2021 at 11:32 AM, revealed SRNA's were expected to report to the nurse if a resident was not eating or drinking. She further revealed the Kiosk system gave a notification to the clinical managers when a resident had not eaten but, she was unsure if it notified the floor nurses as well. She further revealed hydration and meal intakes were reviewed in daily clinical meeting and weekly meetings to discuss weight loss. The ADON further stated residents were weighed on admission, daily for three (3) days then weekly and if the resident's weights were stable they were removed from weekly weights and to monthly weights. She revealed night shift obtained all the weekly weights on Wednesday and they were discussed in the weekly meeting with the dietician on Mondays. The ADON stated Resident #2 had transferred to the 100 Hall on 03/26/2021 and didn't understand why the resident was not weighed after the transfer. She stated she reviewed the residents' intake records daily by running a look back report in Point Click Care (PCC), discuss the reports in the morning meetings, and notify the NP and dietician if something was off. Interview with the Registered Dietician (RD), on 06/02/2021 at 11:14 AM, revealed clinical meetings were held weekly on Monday's to discuss residents who were at nutritional risk and any residents on weekly weights. She further stated residents were weighed on admission and weekly for four weeks and if the weights were stable they were removed from weekly weights. She stated the Clinical Directors, ADON, and DON attended the meetings. She revealed Resident #2 had orders fpr Magic Cup with meals and [MEDICATION(S)] for appetite stimulate upon admission. The RD stated she was not aware of Resident #2's significant weight loss until 04/28/2021. She revealed nursing monitored intakes, meals and fluids and there were no notes in PCC addressing weekly weights or weight loss until 04/28/2021. Additional interview with the RD on 06/07/2021 at 11:47 AM, revealed she reviewed admission notes, admission height and weight and diagnosis. She stated the resident had nausea and vomiting noted on the admission assessment. The RD stated she calculated the fluids and calories requirements based on the resident's body weight. She further revealed all residents get the required 1500 ml of fluids combined on their meal trays and nursing monitored fluid and meal intakes. The RD stated she would expect nursing staff to make her aware of any concerns related to the resident's decreased intake. She further revealed she had not been made aware of any concerns with Resident #2's intakes or weight loss. Interview with the Director of Nursing (DON), on 06/08/2021 at 12:20 PM, revealed she expected all residents to be weighed on admission, daily for three (3) days then weekly for four (4) weeks. She further stated during weekly meetings residents on weekly weights were discussed and determine if their weights were stable and if weekly weights should be continued. She further revealed the resident was discussed in the weekly meetings, but she could not recall being made aware of the resident's weight loss. The DON revealed she expected the SRNA's to inform the nurse if a resident was not eating or drinking and from there the nurse should inform the Clinical Director, Dietician and APRN, or physician. She further revealed outcomes for not monitoring intakes could be very negative. She stated, We offer but we can't make residents eat or drink.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to revise the comprehensive care plans for two (2) of three (3) sampled residents (Resident #1 and Resident #2 ). Review of the Comprehensive Care Plan in Point Click Care for Resident #1, initiated 02/04/2021, revealed the Fall Care Plan and the Pain and Activity of Daily Living care plans were not updated or revised to address the resident's pain after the 02/15/2021 fall with injury. In addition, staff interviews revealed they were unaware of the hospital discharge plan of care instruction that stated the resident was to remain bed bound due to spinal fractures. Interview with Registered Dietician, on 06/04/2021 at 11:14 AM, revealed when she noted Resident #'2's 10.9% weight loss, she should have updated the care plan, including the resident's goal and implemented new interventions. Record review revealed from 03/16/2021 through 05/04/2021, Resident #2 did not meet his/her fluid or nutritional needs. Resident #2 was transferred to the hospital 05/04/2021. The resident's labs were assessed to be critical. Resident #2 was diagnosed with Metabolic Acidosis, Severe [CONDITION(S)], [CONDITION(S)], Acute Kidney Injury and Severe Malnutrition. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further revealed it will incorporate identified problem areas. 1. Record review revealed the facility admitted Resident #1 on 01/26/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated cognitive impairment. Record review revealed Resident #1 had a fall from the bed on 02/15/2021 and again on 02/21/2021 while trying to reach his/her call light that was out of reach. Review of the Fall Scene Investigation Reports, dated 02/15/2021 and 02/21/2021, revealed Resident #1 fell out of the bed while trying to get to the call light. Review of emergency room record dated 02/18/2021 revealed Resident #1 has a left humeral head fracture, fracture of [MEDICATION(S)] vertebra 12, Lumbar 4 and 5 vertebra, related to the 02/15/2021 fall. Review of emergency room record of 02/21/2021 revealed a right nasal bone fracture, which was related to the 02/21/ fall. Review of the Initial Fall Risk Evaluation Care Plan, dated 01/26/2021, revealed Resident #1 was at High Risk for falls related to total score greater than 10. Interventions included: Physical and Occupational therapy evaluate and treat per recommendation; bed in low position; items within reach, i.e. call light, TV remote, water pitcher, etc.; staff to offer assist to bathroom or offer urinal/bedpan at night to assure safety for seven (7) days; fall risk evaluation; and Blood Pressure lying and sitting for three (3) days. Review of the Comprehensive Care Plan in Point Click Care, initiated 02/04/2021 revealed the Fall Care Plan and the Pain and Activity of Daily Living care plans were not updated or revised to address the resident's pain after the 02/15/2021 fall with injury. Interview with LPN #2, on 06/07/2021 at 4:30 PM, revealed Resident #1 was complaining of shoulder pain by the end of my shift and the information was passed on to day shift. LPN #2 revealed Resident #1 was not on a low bed at the time of the fall and it was the intervention he added to the care plan in the computer. Interview with Director of Nursing (DON), on 06/04/2021 at 12:08 PM, revealed she expected the nurses to update the care plan with new interventions. She stated falls were reviewed each day in clinical meeting and if needed the care plans were updated at that time by the clinical team. 2. Review of Resident #2's closed record, revealed the facility admitted the resident on 03/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission Minimum Data Set (MDS) assessment, dated 03/22/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was cognitively impaired. Review of Resident #2's Comprehensive Care Plan, dated on 03/23/2021, revealed the resident required staff assistance of one person with meals. The care plan further revealed Resident #2 was assessed to be nutritionally at risk and the goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within three (3) pounds, no signs and symptoms of malnutrition and consume at least fifty (50) percent of meals through review date of 06/20/2021. Continued review of the care plan revealed interventions included: staff to encourage good fluid intake and offer substitutes for foods not eaten or disliked, monitor for signs and symptoms of malnutrition, emaciation, muscle wasting, and significant weight loss, three (3) pounds in one week, greater than five (5) percent in one month, greater than 7.5% in three (3) months and greater than 10% in six (6) months, monitor the resident for signs and symptoms of dysphagia, refusing to eat, and holding food in mouth, obtaining and monitoring laboratory values, reporting to physician and following up as needed. Review of Resident #2's weight record, revealed on 03/17/2021, the admission weight was 137 pounds, on 03/18/2021 and 138.5 pounds. The re-weight on 03/18/2021 was 133.5 pounds, on 03/20/2021 - 133.0 pounds, on 03/25/2021, 127.0 pounds a 7.29% weight loss in eight (8 days. Further review of the resident's weight record revealed he/she weighed 122.0 pounds on 04/26/2021, a fifteen (15) pound weight loss, 10.9 % since admission to the facility on [DATE]. However, further review of the record revealed no documented evidence Resident #2's care plan had been revised to address the resident's weight loss. Record review revealed from 03/16/2021 through 05/04/2021, Resident #2 did not meet his/her fluid or nutritional needs. Staff completed a hydration and nutrition risk assessment during this time frame; however, the facility failed to identify the resident was at risk for dehydration and was malnourished. Resident #2 was transferred to the hospital 05/04/2021. The resident's labs were assessed to be critical. Resident #2 was diagnosed with Metabolic Acidosis, Severe [CONDITION(S)], [CONDITION(S)], Acute Kidney Injury and Severe Malnutrition. Interview with Registered Dietician, on 06/04/2021 at 11:14 AM, revealed when she noted Resident #'2's 10.9% weight loss on 04/28/2021, and stated she should have updated the care plan, including the resident's goal and implemented new interventions. Interview with DON, on 06/04/2021 at 12:08 PM, revealed she expected the Clinical Directors to update the care plan with new interventions during the weekly nutrition/clinical meeting with the RD or if there had been a change with the resident. Interview with Clinical Director, (CD) on 06/04/2021 at 9:34 AM, revealed the facility had weekly clinical meetings to discuss residents on weekly weights, weight loss, wounds, and other concerns. She revealed she was not aware of Resident #2's weight loss until the weekly meeting at the end of April. The CD further stated the care plan should have been updated during the At Risk meeting on 04/28/2021 when Resident #2 was noted to have a weight loss. She further revealed the resident should have been on weekly weights. The Clinical Director stated the aides documented intakes in the Kiosk and she expected to be made aware if a resident was not eating or drinking. Interview with DON, on 06/04/2021 at 12:08 PM, revealed she expected the Clinical Directors to update the care plan with new interventions during the weekly nutrition/clinical meeting with the RD or if there had been a change with the resident.

Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observation and interview revealed staff who work on the 100 Hall and 200 Hall of the facility enter the building through the facility's 100 Hall and 200 Hall doors after clocking in for work. Staff then go to the Nurse's Station to be screened for signs/symptoms of COVID-19. Further observation revealed the Nurse's Station where staff were screened was in the center of the hallway where resident rooms were located, and not at an entrance to the facility. The findings include: Review of the facility policy, COVID-19 Employee Screen Policy, dated 03/16/2020, revealed It is the policy of Superior Care Home to screen and detect, to the best of its ability, signs and symptoms in its staff related to the COVID-19 virus. Further review of the policy revealed 1. At the beginning of each shift, each staff member's temperature will be taken by a licensed nurse. 2. The temperature will be recorded onto the COVID-19 Employee Screen form along with other signs and symptoms such as: cough, sore throat, shortness of breath, or other respiratory symptoms. 3. If the staff member has a temperature, that staff member will be excused from his/her duties and will be asked to see his/her PCP. 4. If the staff member is found to have a positive COVID-19 screen from his/her PCP, that staff member will be excused from his/her duties for a 14-day period. The facility's sick leave policy will apply. 5. The staff member may return to work only after the date the staff member's PCP has written on a doctor's excuse. Observation during a walk-through of the facility, and interview with the Infection Control Nurse, on 10/22/2020 at 3:15 PM, revealed staff were screened at the Nurse's Station on 100 Hall, 200 Hall, 300 Hall, and 400 Hall; however, on the 100 Hall and 200 Hall, staff have to pass by resident rooms prior to being screened at the Nurse's Station. Interview with Licensed Practical Nurse (LPN) #1, on 10/26/2020 at 9:28 AM, revealed staff would come to their assigned units before being screened and nightshift would come in the front door, directly on the 100 Hall, through a resident care area before being screened. She stated she thought this was changed on Friday (10/23/2020). Interview with the Environmental Services (EVS) Supervisor, on 10/23/2020 at 12:15 PM, revealed EVS staff were going to the Nurse's Station, wherever they were assigned, which meant going through a resident care area to get screened. The EVS Supervisor stated as of this morning (10/23/2020), EVS would use the back door near Maintenance to enter the facility and get screened there, which was not a resident care area. If no one was there, then staff should call the Nurse's Station, so he or she will come screen you. Interview with Registered Nurse (RN) #1, on 10/26/2020 at 10:09 AM, revealed prior to today she would enter the building through the back door by the service area, go to the training room to get Personal Protective Equipment (PPE), fill out a questionnaire, then go to the Nurse's Station on the 100 Hall to get her temperature taken by the nurse, and get screened at that time. She stated effective today (10/26/2020), she had to come to the front door for screening. Interview with the Director of Nursing (DON), on 10/26/2020 at 3:50 PM, revealed staff should always be screened prior to being in a resident care area. She stated the facility was constantly making changes depending on whatever was going on in the community, through prevention and monitoring. Interview with the Administrator, on 10/21/2020 at 9:00 AM, revealed according to test results from Monday (10/19/2020), there were five (5) staff who tested positive, and were currently out of the building. However, they were waiting for more rest results. She stated they continued to test staff and residents twice per week every week. Interview with the facility's Nurse Consultant, on 10/23/2020 at 1:04 PM, revealed the facility had to reinforce the screening process the last few days, as some of the staff had become relaxed in the screening process. She stated the facility continued to monitor for proper screening.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 08/14/19, revealed a red sanitation bucket on the kitchen floor. Review of the facility Census and Condition, dated 08/14/19, revealed eighty-three (83) of eighty-three residents received their meals from the kitchen. The findings include: Review of the facility policy, Sanitizing Food Contact Surfaces, last revised (MONTH) (YEAR), revealed the red buckets should be placed on a lower shelf of the station and positioned as to prevent splash into food, food-contact equipment, linens, and single-serve items, or as required by state or local regulations. Observation of the kitchen during initial tour on 08/14/19 at 8:49 AM, revealed a sanitizing bucket with clean water used for wiping food spills, was on the kitchen floor. Interview with the Dietary Manager on 08/14/19 at 9:03 AM, revealed the bucket should not be on the floor, but placed on a shelf to ensure the cleaning water would not be contaminated.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Resident #23). Resident #23 required to be transferred by two (2) staff with the use of a mechanical lift; however, the MDS Coordinator coded the MDS inaccurately when she coded the resident a (3) for transfers which indicated the resident was highly involved and staff provided non-weight bearing assistance instead of a four (4) which indicated the resident was dependent on staff. The findings include: Review of the RAI Version 3.0 User Manual on Coding instructions for Section G Functional Status, revealed total dependence (4) should be coded if full staff performance occurred every time during the entire 7-day look back period for Activities of Daily Living Self-Performance. Record review revealed the facility readmitted Resident #23 on 05/05/17, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 07/01/19, revealed the facility assessed Resident #23's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS assessment revealed in Section G Functional Status, part B. Transfers for Self-Performance, staff coded a three (3), which indicated the resident was involved with his/her transfers and staff provided weight-bearing support. However, review of the care guide, revealed a maxi-lift with two (2) staff assist were utilized in order to transfer Resident #23. Interview with Resident #23 on 08/16/19 at 8:23 AM, revealed he/she could not walk and staff used a mechanical lift in order to transfer him/her at all times. Interview with Certified Nurse Aid (CNA) #1 on 08/16/19 at 2:24 PM, revealed staff have always transferred Resident #23 with the use of a mechanical lift because the resident was not able to walk, as far as she could recall. Interview with the MDS Coordinator, on 08/16/19 at 11:44 AM, revealed the facility follows the RAI for coding Section G of the MDS. She stated Section G of the MDS related to transfers was marked in error by her. She stated Resident #23 is totally dependent upon staff for transfers and she coded a three (3) instead of a four (4) which would have indicated the resident was totally dependent on staff for transfers. Interview with the Director of Nursing (DON), on 08/16/19 at 2:35 PM, revealed she expected the MDS to be coded accurately to reflect the resident's current status.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure that the resident's right to privacy and confidentiality was honored for one (1) resident not in the selected sample of nineteen (19) residents (Resident #89). Observation during a medication pass in a resident's room revealed Registered Nurse (RN) #1, discussed Resident #89's health related information in the presence of another resident. The findings include: Review of a facility policy titled, Understanding the Basic Concepts -Health Insurance Portability and Accountability Act (HIPPA), not dated, revealed HIPPA is a Federal law that has special privacy and security rules that health agencies must follow. Further review of the policy revealed privacy rules ensure a patient's personal information is not given to others without permission. Observation on 08/16/19 at 9:48 AM, revealed RN #1 spoke of a resident by name, in the presence of another resident, and revealed he/she had just fallen and she would do a skin assessment on him/her when the aides put him/her to bed. Interview with RN #1 on 08/16/19 at 9:52 AM revealed she should not have spoke of another resident by his/her name and provided personal information, in the presence of another resident. RN #1 stated she realized as soon as she spoke about the situation, it could be considered a HIPPA violation. Interview with the Director of Nursing (DON) on 08/16/19 at 2:35 PM, revealed she would expect all staff to not share a resident's personal health information in the presence of other residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure gloving procedures were followed related to a medication pass. Observation on 08/16/19 revealed licensed staff handled a resident's medication with her bare hands. The findings include: Interview with the Director of Nursing (DON) on 08/16/19 at 2:35 PM, revealed the facility did not have a policy that addressed handling medications with bare hands. She stated the facility followed state and federal regulations related to infection control and medication administration. Observation of a medication administration pass on 08/16/19 at 9:48 AM, revealed Registered Nurse (RN) #1, placed her bare finger in a resident's medication cup to move the pills forward prior to pouring them into the resident's mouth, and in the process touched the medications with her bare hand. Interview with RN #1 on 08/16/19 at 9:52 AM, revealed she should not have placed her bare finger in the medication cup because she touched other medications in the process and it was an infection control issue. Further interview with the DON on 08/16/19 at 2:35 PM, revealed nurses were taught they should not touch medications with their bare hands.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was prepared, and distributed under sanitary conditions. Review of the facility Census and Condition, dated 03/28/17, revealed ninety-six (96) of ninety-eight (98) residents received their meals from the kitchen. Observations on all three (3) days of the survey (03/28-30/17), revealed the dietary staff had to walk past the food prep areas to obtain hair nets from a box outside of the Registered Dietician's (RD's) office. In addition, kitchen staff were observed with their hair not adequately restrained. The findings include: Review of the facility policy titled, Hair Restraints, dated 2013, revealed Hair must be restrained to prevent it from being both a direct and indirect vehicle of food contamination. Dislodged hair must be kept from falling onto food-contact surfaces. Additionally, associates must wear hair restraints, such as hats, hair coverings or nets, beard/ mustache restraints and clothing that covers body hair. Hair restraints must be designed and worn to effectively keep hair from contacting exposed food, clean equipment, utensils, linens and single-service and single-use articles. 1. Observation during the initial tour of the kitchen, on 03/28/17 at 2:40 PM until 3:10 PM, revealed the Registered Dietician (RD) failed to wear a hair restraint device. Additionally, the box of hair nets was not available at the entry to the kitchen area and were noted to have been stored outside the Dietary Office, located across from the food preparation area, in the kitchen. Several observations were made of desserts and salads being prepared in this area. Interview with the RD, on 03/28/17 at 3:00 PM, revealed according to facility policy, she did not have to wear a hairnet, as long as she was not working around a food preparation area. 2. Observation on 03/29/17 at 11:40 AM, revealed Dietary Aide (DA) #1 was wearing a baseball-type cap with shoulder-length hair, unrestrained underneath; DA #2 had a section of long hair unsecured out of the hairnet; Cook #1 and Chef #1 both had beards uncovered; and Dish Room Worker #1 wore no hair restraint device. Interview with DA #1 and DA #2, on 03/30/17 at 1:50 PM, revealed they were not aware their hair was not effectively secured. Interview with the RD, on 03/30/17 at 2:00 PM, revealed the hairnets were only available in the middle of the kitchen behind the steam table, in front of a food preparation area and stated they used to have been stored on racks outside the kitchen area and she was not sure why this had been moved. She was unaware of a policy regarding beard covering devices. Interview with the Administrator and Owner, on 03/30/17 at 3:30 PM, revealed this would be reconciled and staff would be re-trained.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to follow their infection control and contact isolation policies for one (1) of twenty (20) sampled residents (Resident #7). Observation on 03/29/17 revealed a staff member entered Resident #7's contact isolation room without the proper Personal Protective Equipment (PPE) in place per facility policy. The findings include: Review of the facility's policy titled, Infection Control, dated 11/28/16, revealed the facility's infection control policy was a guideline to establish standards to minimize the effects of infections to residents and employees, and to provide a safe and sanitary environment to prevent the development and transmission of diseases and infections. Review of the facility's policy titled, Contact Precautions, dated 11/07/12, revealed contact precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Use of contact precautions are used with resident infected by Clostridium Difficile (C. Diff). A Stop-See Nurse sign is to be placed outside the resident's door. Wear a clean, disposable gown when doing direct patient care in which your clothing will have substantial contact with the resident. Record review revealed the facility admitted Resident #7 on 03/10/17 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a [DIAGNOSES REDACTED] Toxin laboratory test, dated 03/26/17, revealed a positive test for[DIAGNOSES REDACTED]. Observation, on 03/29/17 at 9:58 AM, revealed there was a sign outside the resident's door reading See Nurse at Nursing Station and just inside the resident's room was all the proper PPE including gown and gloves. Further observation revealed the MDS Coordinator was sitting on the side of the bed (in direct contact with the resident's environment) while conducting Resident #7's Brief Interview of Mental Status (BIMS) evaluation. She was noted to not have any form of PPE in place such as gloves or gown. Interview with the MDS Coordinator, on 03/29/17 at 10:10 AM, revealed she expected anyone entering a resident's room on contact isolation to wear a gown and gloves. She stated Resident #7 was on contact isolation for[DIAGNOSES REDACTED] and not wearing the protective equipment could cause the spread in infection. She revealed she should have put on PPE when entering Resident #7's room. She stated she was sitting on the side of the resident's bed while conducting the BIMS evaluation and she should have had on gloves and a gown to prevent possible spread of the[DIAGNOSES REDACTED]. infection. Interview with the Clinical Director for Hall 300, on 03/29/17 at 10:04 AM, revealed she expected anyone entering a resident's room on contact isolation to wear a gown and gloves. She stated Resident #7 was on contact isolation for[DIAGNOSES REDACTED]. She further stated if someone did not use the PPE for this or any resident on contact isolation it could result in cross contamination and the spread of the infection to other residents, staff, or visitors. Interview with the Assistant Director of Nursing (ADON), on 03/30/17 at 3:35 PM, revealed she expected all staff to follow the isolation policy. Interview with the Director of Nursing (DON), on 03/30/17 at 3:45 PM, revealed she expected the staff to adhere to the facility policy. She stated not following the policy could cause a potential outbreak of infection. Interview with the Administrator, on 03/30/17 at 4:08 PM, revealed she expected the staff to follow the policy and not following the policy could cause the spread of infection.

Based on interview, record review, and review of the facility's policy, the facility failed to review and revise the care plan for one (1) resident (Resident #1) related to the use of an assistive device, in the selected sample of three (3) residents. The facility failed to develop a plan to improve functional abilities for the resident and failed to update his/her care plan to reflect the use of a lap tray. The findings include: Review of the facility's policy Care Plan Policy, no date, revealed a care plan will be based on the resident's comprehensive assessment and will be developed by the Interdisciplinary Team, which includes the following: Physician, Nursing, Dietician/Dietary Manager, Social Services, Activity Director, Therapists, and Director of Nursing (DON)/Clinical Director. Comprehensive Care Plans will be completed by all disciplines within the guidelines of the Resident Assessment Instrument (RAI) manual. Record review revealed the facility admitted Resident #1 on 07/09/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance of one (1) person for transfers. Further review of the MDS revealed Resident #1 was interviewable with a Brief Interview for Mental Status (BIMS) score of twelve (12). Review of the Certified Nurse Aide (CNA) Self Care Deficit care plan and the Nursing Self Care Deficit care plan, dated 04/27/16, revealed the resident used the half table to his/her wheelchair to assist him/her in reading books. Interview with Resident #1, on 12/18/16 at 2:23 PM, revealed the tray helped to keep me in my chair. Interviews, on 12/18/16, with CNA #1 at 3:02 PM; CNA #3 at 2:20 PM; Licensed Practical Nurse (LPN) #2 at 1:47 PM; LPN #3 at 2:29 PM; and LPN #4 at 2:45 PM, revealed the lap tray for Resident #1 was used for positioning and prevention of falls prior to his/her fall on 11/30/16 and continued to remain in place for the same purpose. Interviews, on 12/19/16, with the Physical Therapist (PT) at 8:53 AM, and the Physical Therapist Assistant (PTA) at 12:40 PM, revealed the lap tray was utilized for positioning in the wheelchair. Interview with the MDS Coordinator, on 12/19/16 at 9:36 AM, revealed the resident leaned over in his/her wheelchair and read books, which was not safe without the tray. She further stated she spoke with the staff regarding the use of the lap tray in the past, but did not talk with them when she completed the last Quarterly MDS assessment on 10/14/16. She stated she she assumed the staff was aware of what the care plan stated, and what the use of the lap table was used for. She further stated if the lap table/tray was used for positioning for the resident, then the care plan should have stated positioning. She revealed originally the lap tray had been used for reading and she was not aware the use of the tray had changed. She revealed nursing should have been aware the tray was used for positioning and the purpose had changed, and therapy should notify the MDS personnel if the purpose changed. She stated after reading the PT note, dated 12/06/16, the lap tray should have been noted on the care plan for positioning and another intervention should have been put into place while it was broken to prevent falls. She stated she was not aware the lap tray had been broken. Interview with the Director of Nursing (DON), on 12/19/16 at 1:25 PM, revealed the lap tray was used for book reading, and was not being used for safety reasons. Interview with the Administrator/Owner, on 12/18/16 at 1:55 PM, revealed the care plan was not updated after the Physical Therapist completed the treatment note on 12/06/16, and documented the lap tray was utilized for positioning. She stated this information should have been communicated to the nursing staff and changed on the care plan.

Based on interview, record review, and review of the facility's policy, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) resident (Resident #1) related to falls, in the selected sample of three (3) residents. The facility failed to implement interventions to reduce hazards and assess for risks consistent with the resident's needs to enhance the resident's function and/or safety while Resident #1's assistive device (lap tray) was broken. The resident sustained [REDACTED]. The findings include: Review of the facility's Fall Policy Statement, dated 03/16, revealed the residents are comprehensively assessed for falls risk in order to avoid injury related to falls and maintain physical functioning as much as possible. A nursing assessment is completed when a fall occurs and a post-fall assessment is used to accurately document possible causative factors, revisions of interventions to prevent further occurrences, and any medical treatment required. The Clinical Director will review or revise the Care Plan as appropriate to assure the identified fall risk issue(s) is/are identified, the altered interventions are initiated, if appropriate, and the post fall assessment is put into place. A Licensed Therapist is requested to screen residents for possible interventions. Record review revealed the facility admitted Resident #1 on 07/09/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance of one (1) person for transfers. Further review of the MDS revealed Resident #1 was interviewable with a Brief Interview for Mental Status (BIMS) score of twelve (12). Review of the Certified Nurse Aide (CNA) Self Care Deficit care plan and the Nursing Self Care Deficit care plan, dated 04/27/16, revealed the resident used the half table to his/her wheelchair to assist in reading books. Review of therapy notes, dated 11/07/16, revealed the resident had a Tinetti Balance Score of eight (8) out of twenty-eight (28); and on 11/28/16, a score of nine (9) out of twenty-eight (28), which indicated the resident was high risk for falls. Review of a Post Fall Evaluation/Post Incident Action form, dated 11/30/16 at 9:20 PM, revealed Resident #1 was sitting in his/her wheelchair and unable to tell the nurse how the fall occurred; however, the resident told a family member on the phone he/she turned around to get some ice and fell . Further review revealed the resident sustained [REDACTED]. An ice pack was applied and the resident was sent to the emergency room for evaluation and treatment. Review of the facility's investigative report, dated 11/30/16 at 9:20 PM, revealed the resident told his/her son he/she turned to get some water off the table and fell out of the wheelchair sustaining an injury. The injury included a hematoma to the left forehead with a skin tear. Further review revealed he/she was unable to tell the nurse how the fall occurred. The nurse's conclusion of the incident revealed the resident turned his/her body to grab the water from his/her table and slid out of his/her chair, which caused the resident to fall forward onto the floor. Review of the emergency room report, dated 11/30/16, no time, revealed Resident #1 was diagnosed with [REDACTED]. Interview with Resident #1, on 12/18/16 at 2:23 PM, revealed the tray helped to keep me in my chair. Interview with Resident #1's Power of Attorney (POA), on 12/18/16 at 1:12 PM, revealed, on 11/30/16, the resident fell out of the chair. He further revealed the lap tray had been broken and was awaiting a new one. He stated the lap tray was what kept the resident from falling or sliding out of the wheelchair. He further stated the resident had the lap tray for several years. He revealed the resident went without the lap tray for approximately two (2) weeks and received a new lap tray about one (1) week after the 11/30/16 fall. Interview with CNA #2, on 12/18/16 at 1:29 PM, revealed Resident #1 did not have his/her lap tray when the fall occurred on 11/30/16, as it was broken at the time. She further stated the resident would press his/her call light, and then get up to go to the bathroom without assistance. She stated she would reinforce to the resident to not go to the bathroom alone. Interview with CNA #3, on 12/18/16 at 2:20 PM, revealed a few weeks ago, the resident did not have the lap tray because of a broken part. She further stated the resident used the lap tray for proper positioning. Interview with CNA #1, on 12/18/16 at 3:02 PM, revealed she was not sure if the resident had the lap tray at the time of the 11/30/16 fall. She stated the lap tray kept the resident from falling because he/she would read books on his/her knees and would be an increase risk for falling. Interview with Licensed Practical Nurse (LPN) #1, on 12/18/16 at 1:37 PM, revealed she did not recall if the resident had a lap tray in place or not when the fall occurred, but had been sitting in his/her wheelchair when the fall occurred. Interview with LPN #2, on 12/18/16 at 1:47 PM, revealed she was working after the resident fell on [DATE]. The broken lap tray was sent off to be fixed and she was not sure if the lap tray had been fixed yet. She further stated the resident used the lap tray for support in the wheelchair. Interview with LPN #3, on 12/18/16 at 2:29 PM, revealed the resident used the lap tray for positioning, reading books, and normal activities of daily living and was not sure how long the resident did without the tray. Interview with LPN #4, on 12/18/16 at 2:45 PM, revealed the resident used his/her lap tray for stability and positioning. She further revealed the resident kept the tray in the down position for use unless toileting. Interview with the Physical Therapist (PT), on 12/19/16 at 8:53 AM, revealed there was an order for [REDACTED]. She stated she performed the Tinetti Balance test and the score of an eight (8) and nine (9) out of twenty-eight (28) indicated a resident was a high falls risk. She further stated the resident was determined a high falls risk upon evaluation. She revealed the resident used the padded lap tray for positioning due to the fact the resident leaned forward in the wheelchair. She stated the lap tray was broken at some point, but unsure about the timeframe. She revealed the resident would have been at increase risk for falls without the lap tray. She further stated she did not assess during the first evaluation on 11/07/16 for the lap tray. She revealed she reassessed the lap tray for appropriateness on 12/06/16 as it was present at that time and was appropriate for positioning and prevention of falls. She further revealed, besides putting another lap tray on the resident on 11/30/16, there was not another positioning device suitable for the resident. She stated the lap tray was not repairable and required a new one to be ordered. She stated the resident has paraspinal muscles which caused him/her to lean forward in the wheelchair, as well as osteoporosis causing poor posture and arthritis. Review of Physical Therapy notes, dated 12/06/16 at 3:44 PM, revealed the resident was reassessed for appropriateness of the lap tray on the wheelchair. Further review revealed the lap tray was originally applied per the Physical Therapist Assistant (PTA) due to the resident leaning forward and falling out of the wheelchair. The resident was able to adjust and remove the lap tray safely from the wheelchair with modified independence. Additional review revealed the resident demonstrated good positioning in the wheelchair with the lap tray in place. Interview with the PTA, on 12/19/16 at 12:40 PM, revealed PT had asked about the lap tray when PT performed the evaluation on Resident #1. She further revealed the lap tray was originally placed on him/her due to the fact the resident would not lay down in the bed when he/she became tired, and while sitting in the wheelchair, her/she would lay half of his/her body across the bed; therefore, Occupational Therapy (OT) originally assessed the tray for positioning. She further stated any device placed on a wheelchair must be evaluated by therapy to ensure safety and easy removal by the resident. After the device has been deemed safe, the information is then communicated to nursing, restorative, and the MDS nurse to follow up with care planning. If the device became broken, something else would be put into place to prevent falls. Interview with Maintenance, on 12/19/16 at 9:24 AM, revealed nursing staff or a resident is supposed to let maintenance know if there is an issue with equipment. If the problem occurred after hours the staff are suppose to tape a note to the maintenance door, unless it was an emergency, and then the staff should call the Maintenance Director. He further stated an aide told him that Resident #1's lap tray was broken, and brought the tray to the Administrator. The Administrator called the distributor and placed an order for [REDACTED]. He stated as soon as the lap tray came in, it was placed on the wheelchair by the Maintenance Director, which was 12/02/16. Interview with the Maintenance Director, on 12/19/16 at 9:17 AM, revealed the nurses call if there is a problem with any equipment. He further stated there was not a tracking system to follow up with equipment needing repair. He stated the Maintenance Assistant brought the broken lap tray to the Administrator, and she ordered a new one. Maintenance installed the tray when it came in. Interview with the Director of Nursing (DON), on 12/19/16 at 1:25 PM, revealed any equipment placed on a wheelchair goes through therapy to ensure the device is appropriate. However, she stated the facility does not have an assessment policy in place to ensure therapy evaluates what devices are used prior to placement. She revealed the reason for the tray has been for books and reading, not for safety; therefore, no quarterly assessment would have been required. She further revealed the tray will now have a quarterly assessment, as therapy had identified it as adaptive equipment. Interview with the Administrator, on 12/17/16 at 3:30 PM, revealed the staff brought the broken tray to her on 11/17/16, and she emailed the supplier the same day to place an order. The order for a lap tray was confirmed on 11/18/16 and arrived to the facility on [DATE], and that was the day Maintenance installed it. Further interview, on 12/18/16 at 2:00 PM, revealed the family requested Resident #1 use the lap tray years ago to lay his/her book on for reading. She further stated nursing was aware the lap tray was broken, and nothing extra was put into place as an extra intervention until the new tray came in.